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Full text of "The pathology and surgical treatment of tumors"

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■ 
^V/ CORNEL1 - UNIVERSITY. 

THE 

Bostwetl p. dottier Cibrarg 

jhCWV* THE GIFT OF 

ROSWELL P. FLOWER 

FOR THE USE OF 

THE N. Y. STATE VETERINARY COLLEGE. 

1897 




Cornell University 
Library 



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http://archive.org/details/cu31924104224567 



THE 



PATHOLOGY 



SURGICAL TREATMENT 



TUMORS 



BY 

N. SENN, M.D., Ph.D., LL.D. 

TROFESSOR OF PRACTICE OF SURGERY AND CLINICAL SURGERY, RUSH MEDICAL COLLEGE; 
PROFESSOR OF SURGERY, CHICAGO POLYCLINIC; ATTENDING SURGEON TO PRESBY- 
TERIAN HOSPITAL ; SUHGEON-IN-CHIEF, ST. JOSEPH'S HOSPITAL, CHICAGO. 



ILLUSTRATED BY 515 ENGRAVINGS, INCLUDING FULL-PAGE 
COLORED PLATES 



PHILADELPHIA 

W. B. SAUNDERS 

925 Walnut Street 

i8 9 5- 



Copyright, 189S, by 
W. B. SAUNDERS. 



WESTCOTT &. THOMSON, PRESS OF 

ELECTROTYPERS. PHILADA. W. B. SAUNDERS, PHILADA 



TO THE MEMORY 



SAMUEL DAVID GROSS 

A MASTER IN SURGERY; A PIONEER IN PATHOLOGICAL ANATnMV; A SURGEON 

HONORED AND REVEREIl WHEREVER HIPPOCRATIC MEDICINE IS TAUGHT 

OR PRACTISED; A MAN WHOSE EMINENT PROFESSIONAL 

REPUTATION WAS CROWNED BY THE PURITY 

(IE HIS PRIVATE CHARACTER, 

THIS WORK IS 

KEVERENTLY AND AFFECTIONATELY INSCRIBED BY HIS FRIENO 

THE AUTHOR. 



PREFACE. 



The appearance of a treatise on " The Pathology and Surgical 
Treatment of Tumors " at this time needs no apology. Books 
specially devoted to this subject are few, and in our text-books and 
systems of surgery this part of surgical pathology is usually condensed 
to a degree incompatible with its scientific and clinical importance. 
Again, the attention and energies of pathologists and surgeons during 
the last quarter of a century have been directed more toward the 
foundation and development of the new science of bacteriology and 
the advancement and improvement of operative technique than to a 
more thorough investigation of the equally important though less 
inviting subject relating to the origin, nature, structure, clinical aspects, 
and treatment of tumors. 

Every teacher of pathology and surgery knows how difficult it is 
to impart to the student a knowledge of the structure and clinical 
tendencies of the different kinds of tumors sufficiently accurate to 
enable him to make a reliable diagnosis at the bedside. The gen- 
eral practitioner often remains painfully conscious of this defect in 
his early training, and the surgeon is frequently in doubt when to 
apply his art or when to pursue a conservative or palliative course 
when applied to for treatment by patients suffering from obscure 
tumors or tumors presenting one or more of the numerous compli- 
cations to which they are subject. 

The author has spent many years in collecting the material for this 
work, and has taken great pains to present it in a manner that should 
prove useful as a text-book for the student, a work of reference for the 
busy practitioner, and a reliable, safe guide for the surgeon. For 
the purpose of simplifying diagnosis a special effort has been made 
to trace every tumor to its proper anatomical starting-point and histo- 



6 PREFACE 

genetic source, and to make a sharp histological and clinical distinction 
between true tumors, inflammatory swellings, and retention-cysts. 

The increase in volume caused by a tumor is due entirely to erratic 
cell-growth from a matrix of embryonal cells of congenital or post- 
natal origin ; the enlargement of a part or an organ caused by chronic 
inflammation which so often simulates a tumor is due to proliferation 
of pre-existing mature cells acted upon by pathogenic micro-organisms 
or their toxines, and to the vascular changes and cell-migration charac- 
teristic of inflammation ; while a retention-cyst essentially consists of 
an accumulation of a physiological secretion in a pre-formed glandular 
space, the result of a mechanical obstruction. 

The classification of tumors in this work is in accord with this 
theory of the origin of tumors. The microbic origin of tumors is 
briefly disposed of, as it has not been established by any convincing 
experimental investigations or clinical observations. Should future 
research demonstrate a direct causative relationship between certain 
as yet unknown bacteria and the growth of some of the tumors, such 
tumors would have to be eliminated from this group of pathological 
products and be classified with the granulomata. 

The first part of this treatise is devoted to a general consideration 
of tumors, and it is this part which is intended more especially for the 
use of students. Following the section on Classification, each class 
of tumors is considered separately, beginning with benign epithelial 
tumors and terminating with sarcoma, to which is appended a section 
on Retention-cysts. It will be observed that by following this course 
each tumor is brought to the notice of the reader three different times. 
Repetitions like these cannot fail in permanently impressing the sub- 
ject upon the memory of the reader. It has been deemed advisable 
to discuss benign tumors first, as they do not deviate so far from the 
normal type of tissue-growth as do malignant tumors of the same 
germinal layer. 

Retention-cysts are not true tumors, but they are discussed in the 
last section of the volume, as their differentiation from tumors is often 
exceedingly difficult, and in their structure and clinical course they 
resemble more closely tumor-formation than the products of inflam- 
mation. A description of each class of tumors is followed by a con- 



PREFACE. 7 

sideration of the topographical distribution of that particular kind of 
tumor in the different regions and organs of the body, with a 
description of the different operative procedures for their removal. 

The intention of the author in illustrating the text so profusely 
was to keep constantly before the reader's eye the microscopical pic- 
ture of the tumor, which in many places is contrasted with the normal 
structure of the tissues corresponding with the anatomical location 
of the tumor. The more difficult operations are fully described and 
illustrated. More than one hundred of the illustrations are original, 
while the remainder were selected from books and medical journals 
not readily accessible to the student and the general practitioner. 

The author desires to acknowledge his indebtedness to Mr. W. B. 
Saunders, who has spared no expense in presenting this book to the 
profession, and to Mr. John Vansant and Mr. Thomas Dagney of his 
publication rooms, for valuable assistance in supervising the details 
of the preparation of the work ; also to Drs. Lecount and Mellish 
for a number of well-executed original drawings. 

N. Senn. 
Chicago, September, 1895. 



CONTENTS. 



PAGK 

I. Origin and Nature of Tumors 17 

Definition, 19. Histological and Clinical Differences between a 
Tumor and an Inflammatory Swelling, 20. Histogenesis, 24. 

II. Morphology and Multiplication of Tumor-cells 28 

Morphology, 28. Karyokinesis, 30. 

III. Anatomy and Biology of Tumors 34 

Blood-vessels, 35. Lymphatic Vessels, 35. Nerves, 36. Biology, 37. 
Relation of Tumors to Adjacent Tissues, 40. 

IV. Pathology of Tumors 42 

Fatty Degeneration, 43. Mucoid Degeneration, 44. Colloid Degen- 
eration, 44. Amyloid Degeneration, 45. Hyaline Degeneration, 45. 
Caseation, 46. Calcification or Cretefaction, 47. Ossification, 48. 
Interstitial Hemorrhage and Thrombosis, 48. Capsule of Tumor, 
51. Lymphatic Glands, 51. Inflammation, 52. Ulceration, 52. 
Grafting of a Malignant upon a Benign Tumor, 53. 

V. Tumors in Plants and Animals 55 

Tumors in Plants, 55. Tumors in Animals, 57. 

VI. Etiology of Tumors 61 

Congenital Tumors. 61. Heredity, 62. Race, 65. Climate, 66. Age, 
66. Sex, 68. Traumatism, 69. Irritation, 70. Inflammation, 70. 
Contagion, 70. 

VII. Clinical Aspects of Benign and Malignant Tumors 72 

Relative Frequency with which Different Organs are Affected by 
Tumors, 72. Benign Tumors, 73. Malignant Tumors, 75. Local 
Infection, 76. Regional Infection, 76. General Infection, 77. Fre- 
quency of Recurrence after Extirpation, 79. Intrinsic Tendency 
of the Tumor to Destroy Life, 80. 

9 



io CONTENTS. 



PAGE: 



VIII. Transformation of Benign Tumors and Post-natal Embryonic 

Tissue into Malignant Tumors 81 

Transformation of Benign into Malignant Tumors, 81. Transforma- 
tion of Embryonic Tissue of Post-natal Origin into Malignant 
Tumors, 85. 

IX. Diagnosis of Tumors 89 

Clinical History, 89. Length of Time Tumor has Existed, 90. Loca- 
tion of Tumor, 90. Rapidity of Growth of Tumor, 90. Pain, 91. 
Tenderness, 91. Examination of the Patient, 92. Examination of 
the Tumor, 94. Tactile Examination, 96. Connection of Tumor 
with the Mother-soil, 97. Resistance and Consistence, 98. Pulsa- 
tion, 102. Tenderness, 102. Crepitation, 102. Auscultation and 
Percussion, 102. The Value of the Microscope as an Aid in the 
Diagnosis of Tumors, 103. 

X. Prognosis of Tumors 10& 

XI. Treatment of Tumors 113. 

Medical Treatment, 113. Radical Operation, 115: Ligation of the 
Principal Blood-vessels Nourishing the Tumor, 116; Galvano- 
puncture, 116; Parenchymatous Injections, 117; Injection of Ery- 
sipelas Toxines, 118; Cauterization, 118; Ligature, 122; Galvano- 
caustic Wire, 124; Ecrasement Lineaire, 125; Avulsion, 126; 
Extirpation, 126. Palliative Treatment, 129. 

XII. Classification of Tumors 131. 

Virchow's Classification, 131. Cohnheim's Classification, 132. Wil- 
liams's Classification, 133. Senn's Classification, 136. 

XIII. Papilloma and Onychoma 137 

Papilloma, 137. Histology and Pathology, 137. Transformation 
into Malignant Tumors, 138. Topography, 141 : Skin, 141 ; Cornu 
Cutaneum, 142; Respiratory Organs, 144; Urinary Organs, 145; 
Female Organs of Generation, 146; Brain, 148. Diagnosis, 148. 
Prognosis, 150. Treatment, 150. Onychoma, 151. 

XIV. Adenoma 152 

Histology and Pathology, 153. Etiology, 155. Topography, 156: 
Skin, 156; Adenoma Sebaceum, 156; Adenoma Sudoriparum, 157; 
Digestive Tract, 158; Nasal Cavities, 159; Uterus and its Append- 
ages, 159; Thyroid Gland, 162; Mammary Gland, 167; Prostate 
Gland, 171; Lachrymal Gland, 172; Parotid Gland, 172; Testicle, 
173; Liver, 174; Kidney, 176. Diagnosis, 176. Prognosis, 177. 
Treatment, 177. 



CONTENT'S. 

XV. Cystoma 

Etiology, 181. Diagnosis, i Si . Prognosis, 182. Topography, 182 
Traumatic Epithelial Cysts, 182 ;- Deep-seated Atheroma, 184 
Mucous Cysts, 186 ; Mesoblastic Cysts, 187 ; Thyroid Gland, 187 
Mammary Gland, 189; Ovary, 190; Vagina, 199; Testicle, 199 
Eye, 199; Cysts of the Vitello-intestinal Duct, 200; Allantoic 
(Urachus) Cysts, 201 ; Bone, 201. 

XVI. Carcinoma 

Definition, 204. Views Past and Present regarding the Origin and 
Nature of Carcinoma, 205. Histogenesis, 209, Histology, 213: 
Squamous-celled Carcinoma, 214; Cylindrical-celled Carcinoma, 
215; Glandular Carcinoma, 216. Malignancy, 216: Local Infec- 
tion, 217; Regional Infection, 221 ; General Infection, 226. Eti- 
ology, 232 : Heredity, 232 ; Traumatism, 234; Age, 234; Climate, 
236; Mental Depression, 236; Tuberculosis, 237 ; Prolonged Irri- 
tation and Inflammation, 237 ; Microbes, 239. Pathology, 241. 
Histological Varieties of Carcinoma, 249 : Squamous-celled Car- 
cinoma, 249; Cylindrical-celled Carcinoma, 251 ; Glandular Car- 
cinoma, 252. Diagnosis, 255. Prognosis, 263. Treatment, 265 : 
Palliative Operations, 267 ; Radical Operations, 269. Topography, 
272: Skin, 272; Lip, 278; Face, 279; Mouth, 286; Tonsil, 288; 
Tongue, 289 ; Parotid, 295 ; Thyroid, 297 : Mammary Gland, 300 ; 
GLsophagus, 319; Stomach, 322; Intestines, 331 ; Rectum, 336; 
Testicle, 342 ; Penis, 343 ; Ovary, 346 ; Uterus, 349 ; External 
Female Generative Organs, 366 ; Eye, 368 ; Bladder, 368 ; 
Kidney, 370. 

XVII. Fibroma 

Definition, 375. Histogenesis and Histology, 375. Retrograde Meta- 
morphoses, 378. Etiology, 379. Symptoms and Diagnosis, 379. 
Prognosis, 380. Treatment, 381. Topography, 381 : Skin, 381 ; 
Mucous Surfaces, 384; Subcutaneous Connective Tissue, 384; 
Abdominal Wall, 385; Nose, 388; Mammary Gland, 390; 
Uterus, 391; Ovary, 391; Vulva, 392; Gums, 393; Periosteum 
and Bone, 394; Serous Surfaces, 395. Cholesteatoma, 395. 

XVIII. Lipoma 

Definition, 397. Histology, 397. Regressive Metamorphoses, 398. 
Anatomical Varieties, 398. Symptoms and Diagnosis, 399. Prog- 
nosis, 400. Treatment, 401. Topography, 401 : Subcutaneous 
Adipose Tissue, 401 ; Eyelids, 403 ; Subserous Lipoma, 403 ; 
Submucous Lipoma, 404 ; Meninges of the Brain and Spinal Cord, 
405; Intermuscular Lipoma, 406 ; Periosteum, 406; Joints, 407 ; 
Tendon-sheaths, 407 ; Eye, 407 ; Broad Ligament, 407 ; Vulva, 
407 ; Scrotum, 407. 



12 



CONTENTS. 



XIX. Myoma 4o8 

Definition, 408. Histology, 409. Etiology, 410. Symptoms and 
Diagnosis, 410. Prognosis, 410. Treatment, 411. Topography, 
411 : Skin, 411 ; Intermuscular Spaces, 411 ; Nose, 412; Middle 
Ear, 413; Nerve-sheaths, 414; Glands, 414. 

XX. Chondroma 4'5 

Definition, 415. Origin, 415. Histology, 417. Retrogressive Meta- 
morphoses, 418. Etiology, 419. Symptoms and Diagnosis, 420. 
Prognosis, 420. Treatment, 421. Topography, 421 : Cartilage, 
421; Bone and Periosteum, 422; Joints, 423; Salivary Glands, 
424; Testicle, 425 ; Ovary, 425 ; Connective Tissue, 425. Chon- 
droma Branchiogenes, 425. 

XXI. Osteoma 427 

Definition, 427. Histogenesis, 428. Histology, 428. Anatomical 
Varieties, 430. Symptoms and Diagnosis, 430. Prognosis, 430. 
Treatment, 430. Topography, 431 : Cranial Bones, 431 ; Frontal 
Sinus, 433; External Meatus, 434 ; Brain, 435 ; Epiphyses of the 
Long Bones, 435 ; Muscles and Tendons, 436; Seat of Fracture, 
436; Orbit, 437; Eye, 437 ; Subungual Osteoma, 437. 

XXII. Odontoma 43 8 

Definition, 438. Classification, 438. Epithelial Odontomes, 438. 
Follicular Odontomes, 438. Fibrous Odontomes, 440. Cemen- 
tomes, 440. Compound Follicular Odontomes, 440. Radicular 
Odontomes, 440. Composite Odontomes, 440. 

XXIII. Angioma 442 

Definition, 442. Histogenesis, 443. Histology, 443. Complica- 
tions, 445. Anatomical Varieties, 446. Topography, 452 : 
Skin and Mucous Membranes, 452 ; Deep Connective Tissue, 
453; Bones, 455; Intracranial Angiomata, 456; Liver, 456; 
Mammary Gland, 457 ; Tongue, 457 ; Muscles, 457 ; Larynx, 
458. 

XXIV. Lymphangioma 459 

Definition, 459. Anatomical Varieties, 459. Histology and Histo- 
genesis, 459. Regressive Metamorphoses, 465. Symptoms and 
Diagnosis, 466. Prognosis, 466. Treatment, 467. Topography, 
467 : Tongue, 467 ; Lips, 467 ; Neck, 468 ; Subcutaneous and 
Submucous Connective Tissue, 470 ; Uterus, 470. 

XXV. Lymphoma 471 

Definition, 471. Histology and Histogenesis, 473. Retrograde 
Metamorphoses, 473. Symptoms and Diagnosis, 474. Treat- 
ment, 477. 



CONTENTS. 13 

PAGE 

XXVI. Myoma 478 

Definition, 478. Embryology, 478. Rhabdomyoma, 479. Leio- 
myoma, 480. Histology and Histogenesis, 480. Regressive 
Metamorphoses, 483. Symptoms and Diagnosis, 484. Prog- 
nosis, 485. Treatment, 485. Topography, 485 : Uterus, 485 ; 
Broad Ligament, 511; Fallopian Tube, 512 ; Alimentary Canal, 
513; Pharynx, 513; (Esophagus, 513; Stomach, 514; Small 
Intestines, 514; Rectum, 514; Bladder, 515. 

XXVII. Neuroma 516 

Definition, 516. Embryology, 516. Histology and Histogenesis, 
516. Regressive Metamorphoses, 522. Etiology, 522. Symp- 
toms and Diagnosis, 522. Prognosis, 523. Treatment, 523. 
Topography, 524 : Multiple Neurofibromata, 524 ; Cranial 
Nerves, 525 ; Spinal Nerves, 525 ; Upper Extremity, 525 ; 
Lower Extremity, 526; Plexiform Neuroma, 527; Vulva, 527; 
Prepuce, 528. 

XXVIII. Sarcoma 529 

Definition, 529. Histology and Histogenesis, 530. Morphology 
of Sarcoma-cells, 534. Histological Varieties, 535. Regressive 
Metamorphoses, 551. Local and General Infection, 554. Meta- 
stasis, 557. Etiology, 559. Symptoms and Diagnosis, 561. 
Prognosis, 564. Treatment, 564. Topography, 567 : Skin, 
567 ; Submucous Connective Tissue, 569 ; Fascial Sarcoma, 
570 ; Lymphatic Glands, 572 ; Bones, 574 ; Mammary Gland, 
592; Salivary Glands, 594; Tongue, 596; Tonsil, 596; Intes- 
tinal Canal, 596; Omentum, 597 ; Kidney, 597; Uterus, 600; 
Ovary, 602 ; Vagina, 603 ; Vulva, 603 ; Testicle, 603 ; Brain 
and its Envelopes, 605 ; Eye, 605 ; Bladder, 605 ; Prostate, 606. 

XXIX. Teratoma 607 

Definition, 607. Origin, 607. Endogenous Teratomata, 609. Ec- 
togenous Teratomata, 610. Branchial Cysts, 613. Embry- 
ology and Anatomy, 613. History, 615. Classification, 616. 
Mucous Branchial Cysts, 618. Atheromatous Branchial Cysts, 
618. Serous Branchial Cysts, 618. Hemato-cysts of Branchial 
Clefts, 619. Etiology, 620. Diagnosis, 621. Prognosis, 621. 
Treatment, 622. Dermoid Cysts, 625. Definition, 626. His- 
tology, 626. Regressive Metamorphoses, 629. Diagnosis, 631. 
Prognosis, 631. Treatment, 632. Topography, 632: Trunk, 
632 ; Thorax, 633 ; Face, 635 ; Palate and Pharynx, 637 ; 
Scalp and Dura Mater, 638 ; Eye, 639 ; Tongue, 639 ; Rec- 
tum, 641 ; Auricle, 642 ; Ovary, 643 ; Scrotum, 648. 



14 CONTENTS. 



PAGE 



XXX. Retention-cysts 649 

Definition, 649. Histology, 650. Etiology, 652. Symptoms and 
Diagnosis, 653. Prognosis, 656. Topography, 657 : Thyroid 
Gland, 657; Ovary, 657; Skin, 658; Mucous Membrane, 660; 
Hydrokolpos, 663 ; Hydrometra, 663 ; Hydrosalpinx, 664 ; Trachea 
and Bronchial Tubes, 666 ; Appendix Vermiformis, 666 ; Bile- 
ducts, 667 ; Pancreas, 670 ; Kidney, 691 ; Testicle, 698 ; Mammary 
Gland, 699 ; Salivary Glands, 700. 



INDEX 703 



PATHOLOGY 



SURGICAL TREATMENT 



TUMORS. 



THE 

PATHOLOGY AND SURGICAL TREATMENT 



OF 



TUMORS, 



I. ORIGIN AND NATURE OF TUMORS. 

The subject of tumors is one of the much-neglected departments 
of surgical pathology. Laboratory investigation, experimental research, 
and clinical observations have revolutionized the etiology and pathology 
of inflammatory diseases during the last decade. During that time the 
attention of pathologists has been occupied largely in the etiological 
and pathological elucidation of infective diseases, while surgeons have 
expended their energies in enlarging the scope of operative surgery 
by an increased knowledge thus gained, and by the diminution of the 
immediate and remote risks to life of operative procedures attending 
the general adoption of antiseptic and aseptic precautions. The benefit 
to humanity in the saving of life and the lessening of suffering derived 
from these investigations and from improved practice is incalculable. 
The great work initiated by Pasteur, Lister, and Koch has inaugurated 
a new era in the study and treatment of disease, and must serve as 
a permanent foundation for all future investigations. When we realize 
the amount of suffering and the number of deaths resulting from tumors, 
it appears somewhat strange that this vast department of pathology 
has received so little attention on the part of modern investigators. 
It is true that recently a great deal of work has been done to establish 
the microbic origin of malignant tumors, but no positive results have 
been obtained so far, and we must confess that but little additional 
light has been shed on the etiology and pathology of tumors since 
the epoch-making labors of Virchow and Cohnheim. 

History. — The old authors regarded tumors as something entirely 
foreign grafted upon the organism. John Hunter taught that a drop 
of blood, being accidentally extravasated, became organized and as- 
sumed a growth independent of the adjacent tissues, and continued to 
grow till it was limited by some obstacle opposed to it. Effusion of 



18 PATHOLOGY AND TREATMENT OF TUMORS. 

lymph has been considered as a possible cause. It was suggested that 
in the development of the tumors the lymph played the same role 
claimed by Hunter for the extra-vascular blood. Chronic inflammation 
was regarded for a long time as the essential etiological factor. These 
and many other vague theories advanced in regard to the origin and 
nature of tumors prior to the time they were recognized as a part of 
the body they inhabited, the result of proliferation of pre-existing cells, 
do not merit an extended discussion in a modern text-book. Schleiden 
established the cell theory which inaugurated the science of biology ; 
Schwann showed from a cellular basis the analogy of the structure of 
plants and of animals. 

The study of tumors in plants and in the lower animals has done 
much in adding to our knowledge of the etiology and pathology of 
tumors. Pathological processes in plants are much simpler than in 
animals, owing to the absence in the former of many complicating fac- 
tors, such as nerves and blood-vessels ; at the same time, the plants are 
constructed upon a much simpler embryological plan. Both animal 
and vegetable cells have in common the nitrogenous carbon compound 
called " protoplasm." Johannes Muller applied the cell theory to the 
study of tumors. Virchow elaborated this doctrine in establishing by 
his immortal researches the motto of his great work on cellular path- 
ology, Omnis celhila e ccllula. Cohnheim imparted a new stimulus to 
the study of tumors by advancing a novel theory in reference to their 
origin. Virchow taught that an epithelial tumor could develop from 
connective tissue. Cohnheim referred every tumor to its proper embry- 
onic layer, and claimed that a tumor never had its origin from mature 
tissue, but always developed from a matrix of embryonic tissue. This 
essential tumor-matrix he traced back to its embryological source. He 
believed that during the process of cell-differentiation in the embryo 
groups of cells not utilized in the growth of the embryo, or displaced, 
were arrested in their further development, and remained in a latent 
condition until their activity was awakened later, when the product of 
their proliferation resulted in the formation of a tumor. This theory 
found many supporters, but at the present time only a few authors 
uphold it in its entirety. As we shall see further on, it has much to 
recommend it, but it does not satisfactorily explain the origin of all 
tumors. In the absence of better proof of the origin of tumors, the 
writer will adhere to the doctrine advanced by Cohnheim, and in addi- 
tion to it will claim that the essential tumor-matrix may be composed 
of embryonic cells, the offspring of mature cells which for some reason 
have failed to undergo transformation into tissue of a higher type and 
which may remain in a latent, immature state for an indefinite period 



ORIGIN AND NATURE OF TUMORS. 

of time, to become, under the influence of either hereditary or acqu 
exciting causes, the essential starting-point of a tumor. 

Definition. — So long as our ideas in reference to the origin 
nature of tumors rest exclusively on a theoretical basis, it is evi 
that no satisfactory definition can be given. The definition of < 
author must necessarily vary according to his views on the sub 
A few definitions will be given to corroborate the correctness of 
statement. John Hunter thus defines a tumor : "A tumor is a circ 
scribed substance produced by disease, and different in its nature 
consistence from the surrounding parts." " Neoplasm is a new grc 
characterized by histological diversity from the matrix in whic 
grows," is the description of a tumor given by J. Bland Sutton, 
regards the characteristic feature of a tumor as an " active multip 
tion of cells which takes place independently of inflammatory 
cesses." The process which leads to the formation of tumors he < 
" a monstrosity in the development of cells." Liicke wrote on 
subject of tumors from the standpoint that a tumor is " an increas 
volume by the production of new tissue without a corresponding pi 
ological function." Cohnheim, in consonance with his definite ii 
concerning the origin of tumors from embryonic tissue, and the diffen 
between the character of the tissues of which they are composed 
the structure of the tissues in their immediate vicinity, describes a tu 
as " a circumscribed, atypical production of tissue from a matrix 
superabundant or erratic deposit of embryonic elements." From tl 
definitions it becomes apparent how difficult it is to give even 
approximately correct definition of a tumor. " Many pathologists 1 
regarded tumors as a localized form of hypertrophy, but upon mal 
a closer comparison we find that, to whatever extent the adapted hy 
trophy may develop, the overgrown part maintains itself in the noi 
type of shape and structure, while a tumor is essentially a devia 
from the normal type of the body in which it grows, and, as a rule, 
longer it exists the more marked becomes the deviation " (Willia 
One of the greatest difficulties in the way of a proper appreciatioi 
what is meant by a tumor is a failure on the part of authors and te; 
ers to draw a dividing-line between tumors and inflammatory swelli 
That tumors should have been confounded with inflammatory swell 
before the essential causes of the latter were discovered and undersi 
is not strange, but that these entirely different pathological proa 
should not be separated sharply at the present time is inexcusable 

It has been the writer's custom for ten years, in his lectures, didj 
and clinical, to make a sharp distinction between a tumor, an infl 
matory swelling, and retention-cysts. In writing this book this 



20 PATHOLOGY AND TREATMENT OF TUMORS. 

tinction will be maintained by eliminating from discussion all affections 
of which the microbic origin has been established, as well as swellings 
caused by retention of a physiological secretion, the latter of which 
will be discussed in a separate part of the book, and the definition of 
a tumor will therefore be framed upon a more limited basis. The 
definition of a tumor should explain its origin, its histological character- 
istics, and its behavior toward its immediate environment. A tumor is 
a localized increase of tissue, the product of tissue-proliferation of embry- 
onic cells of congenital or post-natal origin, produced independently of mi- 
crobic causes. This definition refers all tumors histogenetically to embry- 
onic cells, which, according to Cohnheim, may be of congenital origin, 
or which, according to the writer's views, may also be of post-natal 
origin, being derived from pre-existing mature tissue in consequence 
of injury or disease, and, failing to undergo the normal transformation, 
may give rise to tumor-formation in the same manner as embiyonic 
cells of fetal origin. This definition also excludes mature tissue and 
pathogenic microbes as etiological factors in the production of tumors, 
thus establishing a well-defined line between a true tumor and an 
inflammatory swelling. It is not necessary to include absence of func- 
tion in the definition, as this applies equally, if not more forcibly, to 
swellings of an inflammatory origin. The writer does not claim that 
this definition is above criticism, but it will convey to the student what 
is so essential in teaching — a correct idea concerning the histogenesis 
and the essential pathological features of tumors, which knowledge will 
enable him, later, at the bedside to make a correct differential diagnosis 
between a true tumor and an infective swelling. 

Histological and Clinical Differences between a Tumor and an 
Inflammatory Swelling-. — According to our definition, the most im- 
portant histological difference between a tumor and a swelling caused 
by infection consists in the fact that in the former the localized increase 
of tissue is the result of proliferation of embryonic cells (of pre- or post- 
natal origin) zvhich are not utilized in the growth and development 
of the body or in the repair of injured or diseased parts, constituting 
thus a process entirely distinct and independent of the tissues in its 
immediate vicinity ; while an inflammatory swelling results from tissue- 
proliferation provoked by the action of pathogenic microbes or their 
toxines upon pre-existing mature tissue-cells. The incipient pathological 
product is therefore always more localized and better defined in tumor- 
formation than in inflammatory affections. A benign tumor always 
remains local, tissue-growth being limited to the fixed primary matrix. 
A malignant tumor has a similar local origin, but it gives rise to dissem- 
ination by migration of cells into the adjacent tissues or by their trans- 



portation to distant parts through the lymphatic or general circulati 
In the production of an inflammatory swelling the fixed tissue-a 
which have been exposed to pathogenic microbes or to their toxii 
participate ; the new cells produced mingle with the corpuscular € 
ments of the blood, reaching the inflamed area through damaged c; 
illary walls caused by the same agents, and constituting with the tra 
udation the inflammatory product. Inflammatory affections lack fn 
the very beginning the localized character of a true tumor. Progress 
and often very speedy extension by continuity and contiguity of stru 
ure is one of the most conspicuous clinical features of inflammatory c 
eases as compared with tumor-formation, and the existence or abser 
of such manifestations is often of great importance to the surgeon 
making a correct differential diagnosis between a tumor and an infla 
matory swelling. Another important point in the early differentiati 
between a tumor and a swelling of infective origin is the durability 
the new tissue-product. The tissue of which a tumor is composed 
permanent. While in cases of progressive marasmus the subcutanec 
fat disappears ultimately almost completely, a fatty tumor in such 
individual remains unaffected, showing its independence from the g< 
eral laws of nutrition and waste that govern the body. A tumor tie; 
disappears except by removal or destruction. There is no authentical 
record of spontaneous disappearance of a tumor or of disappearar 
of a tumor under any kind of internal medication. In all cases 
which such a termination is said to have taken place we have instani 
in which an infective swelling was mistaken for a tumor. The grov 
of a tumor is usually progressive. Some of the benign tumors, su 
as neuroma and osteoma, reach a certain size, when further growth 
spontaneously arrested. The nearer the tumor-elements resemble n 
mal tissue, the greater the probability of spontaneous cessation 
growth. The inflammatory product, whether the result of an aci 
or of a chronic process, is composed of tissue which is destined to si 
cumb sooner or later to the microbic influences which produced 1 
inflammation. The blood-corpuscles and the embryonic cells, the pre 
uct of the fixed tissue-cells, are destroyed by the primary cause of 1 
inflammation, either quickly or slowly according to the type and intens 
of the inflammatory process. One kind of swelling which has b& 
and still is, erroneously designated as a tumor is the struma miasmati 
According to our views, a struma due to miasmatic causes is not 
tumor, because the early use of proper therapeutic agents, such as t 
internal and external use of iodine, by removing or rendering harmb 
the primary, as yet unknown microbic cause, succeeds in effecting 
cure. Under the influence of iodine fatty degeneration, disintegrate 



22 PATHOLOGY AND TREATMENT OF TUMORS. 

and absorption of the cells of a parenchymatous struma are effected 
and a restitution ad integrum takes place. The swelling or pseudo- 
tumor disappears because the remedy administered has succeeded in 
removing or in neutralizing the primary cause. A hyperplasia of tissue 
due to an infective cause is amenable to absorption or removal on 
removal of the primary cause, but no such termination can be expected 
in the case of a tumor, whatever its structure and character may be. 
We must therefore regard permanency of the new tissue as one of the 
evidences in favor of a doubtful enlargement being a tme tumor ; while 
early, and especially acute, degenerative changes would indicate an inflam- 
matory origin. The general symptoms are also to be taken into con- 
sideration in the differential diagnosis between a tumor and an inflam- 
matory swelling. Acute suppurative inflammation is attended by such 
violent local and general symptoms that it is seldom mistaken for 
malignant disease. Chronic inflammatory affections, such as tubercu- 
losis, gumma, and actinomycosis, are often mistaken for tumor, and 
vice versa. Local and general increase of temperature is usually absent 
in all benign tumors, and is either absent or only slightly increased in 
malignant tumors. In chronic inflammatory affections a slight rise in the 
local and general temperature is often observed. The use of the clinical 
thermometer is therefore indicated in obscure cases in making a differ- 
ential diagnosis between a tumor and an inflammatory affection. The 
exclusion of the granulomata (granulation-swellings) produced by the 
bacillus of tuberculosis, the actinomyces, the unknown microbe of 
syphilis, and the bacillus of glanders from the list of tumors has greatly 
narrowed the field of this part of pathology, and it is possible that 
further restriction will take place when convincing proof can be fur- 
nished of the microbic origin of one or of both varieties of malignant 
tumors. As soon as it can satisfactorily be shown that carcinoma and 
sarcoma are caused by microbes, they must be classified with infective 
swellings, and not with tumors. From the present standpoint of patho- 
logical and bacteriological investigations we are forced to include these 
affections among the non-infective neoplasms. Enlargement of the 
superficial veins and oedema, such common symptoms of inflammatory 
lesions, are occasionally present in rapidly-growing malignant tumors ; 
in fact, it may be stated that the nearer a malignant tumor resembles 
inflammation, the greater is its malignancy. 

Histogenesis. — A tumor never originates de novo, but is always an 
integral part of the organism, the product of tissue-proliferation from 
a matrix of embryonic cells. Tumor-formation consists in the growth 
and development of pre-existing immature tissue-elements. The struct- 
ure and character of a tumor depend upon the stage of the arrested cell- 



OKIOIJS AJMV JSIATUKK OF TUMORS. 23 

growth and the embryonic layer from which the matrix is derived. For 
instance, a matrix of epithelial cells from the epiblast in which cell- 
growth was arrested near the completion of the process of differen- 
tiation will in all probability become the starting-point of a benign 
epithelial tumor ; on the other hand, if the development of the same 
cells was arrested at an earlier stage, the proliferation will result in 
tissue of a lower type, and the resulting tumor will be a carcinoma. 
The same holds true of mesoblastic tumors : the more imperfect the 
differentiation, the greater the tendency to the production of a sarcoma 
than to that of a fibroma. The tumor-cells always correspond in type 
to the embryonic cells from which they are derived. In cases of dermoid 
cysts in man we never find heterologous structures ; we always look 
for the products of tissue-proliferation representing the normal tissues 
from the epiblast. While we expect to find in such instances in the 
interior of the tumor hair or other products of epithelial proliferation 
and degeneration, we never find feathers nor any other heterologous 
tissues ; while in birds, when dermoid cysts occur, we find no hair, but 
invariably feathers. So the products of a displaced epiblastic matrix 
always represent normal tissue-elements in an abnormal place. Tumors 
of the connective-tissue type are invariably derived from a matrix of 
mesoblastic tissue, and all epithelial tumors are connected with the 
epiblast or hypoblast or spring from a displaced matrix from either 
of these embryonic layers. As in the majority of cases the tumor- 
matrix is composed of immature cells of fetal origin, it will be necessary 
to discuss in detail the 

Differ entiation of Tissue in the Embryo and the Origin and 
Disposition of the Germinal Layers. — During the earliest stages of 
development the embryo is composed of a mass of indifferent cells. 
At this time it would be impossible to make a distinction under the 
microscope. 

Segmentation of the eggs of the frog was first described in 1836 
by Prevost and Dumas. Pander in 1847 distinguished in the embryo 
of the chick three layers : the external, the serosa ; the internal, the 
mucosa ; and the middle, the muscular layer. This classification of 
the germinal layers corresponds to the more modern into epiblast, 
hypoblast, and mesoblast. Bar, the pupil of Pander, called the ger- 
minal layer stratum proligcrum, and divided the embryonic tissue into 
two principal layers, (1) animal and (2) vegetative. Each of these 
layers he subdivided into two layers, the first (1) skin and (2) muscles, 
the second (1) vascular and (2) mucous. More recently His divides the 
unspecialized tissue of the embryo into two layers, (1) archiblast and 
(2) parablast. The archiblast includes all the tissues which are later 



24 PATHOLOGY AND TREATMENT OF TUMORS. 

transformed into epithelial cells, and it is equivalent to the epiblast 
and the hypoblast. The most active tissue-changes occur during early- 
embryonic life. It is during this time that specialization of the indiffer- 
ent cells takes place, upon which specialization depends the formation 
of different tissues and organs according to the demands of the indi- 
vidual or the adaptation of cells to their immediate environments. The 
division of embryonic tissue into epiblast, hypoblast, and mesoblast 
will be retained in this book, in preference to including the epiblast 
and hypoblast under the one term " archiblast," since in the discussion 
of epithelial tumors the student will more readily comprehend the loca- 
tion of the tumor, as well as the structure of the epithelial cells, by 
separating the epidermal (epiblastic) from the mucous (hypoblastic). 
Based upon the researches of Remak, Reichert, and Kolliker, embry- 
ologists trace all the tissues and organs of vertebrate animals, includ- 
ing man, to these three germinal layers which are found in embryos 
a few days old. In the embryo of the chick two days old (Fig. i) 
these germinal layers can plainly be distinguished, and the complicated 
arrangement between the outer and inner layers and the mesoblast can 
be traced distinctly. 




p dd df 



Fig. i. — Transverse section through embryo of chick two days old; X 100 (after Kolliker) : dd, hypo- 
blast; ch, cord; uw, primitive vertebra; u n h, primitive vertebral canal; a o, primitive aorta; ung, 
primitive urinary channel; sp, cleft in lateral plates (first indication of pleuro-peritoneal cavity), which 
through the same is lost in the hpl and intestinal connective-tissue plates df, which are connected through 
the mesoblast mp: inr, medullary tube; h, epiblast thickened at some points. The embryo at this time is 
composed of two epithelial layers, the outer the epiblast, the inner the hypoblast, connected by the middle, 
the mesoblast. 

A few words concerning the disposition of these germinal layers 
during the differentiation of their cells. From the epiblast are devel- 
oped all the tissues and organs composed of epidermis, the skin, the 
hair, the nails, all cutaneous glands, including those terminating in 
the mouth, also the lens of the eye and the epithelial lining of the 
cavity of the mouth, the nasal passages, and the labyrinth of the ear. 
Reichert was the first to prove that the medullary plate, the primitive 
central nervous system, is formed by the epiblast, and consequently 
that the brain and the spinal cord are epiblastic structures — a discovery 
which was later corroborated by the investigations of Remak and 
Kolliker. 

The epiblast at the stage of development we are now considering 



ORIGIN AND NATURE OF TUMORS. 25 

is arranged in the shape of a double tube — namely, first the covering 
of the whole body (epidermis), and secondly, its central part, the med- 
ullary tube — while the hypoblast constitutes a single tube, the gastro- 
intestinal canal with its glandular appendages. The hypoblast fur- 
nishes the whole epithelial lining of the digestive tract and the urinary 
organs, and from it are also developed the glands of the mucous lining 
and the glandular elements of the pancreas, the liver, the lungs, the 
thyroid, and the kidneys. The middle germinal layer, the mesoblast, 
forms the framework of the body, the bones, the connective tissue, 
the nerves, the muscles, the serous membranes, the vascular organs, 
including the lymphatics and the ductless glands, the thymus, and the 
spleen. The differentiation of the cells that takes place in the embryo 
limits their function to the part or organ to which they belong. No 
transition from one type to another takes place. The law of the specific 
genetic nature of the tissues as now generally recognized is observed in 
the embryo everywhere, and it remains in force during the entire life of 
the individual. In the growth of tumors the same law applies. One 
of the most convincing proofs that the specific nature of imperfectly 
differentiated cells is permanently retained is the familiar clinical fact 
that a displaced matrix of embryonic epithelial cells, isolated from the 
epiblast or hypoblast and buried in the mesoblast, when it becomes the 
starting-point of a tumor invariably results in the formation of an 
epithelial growth. Such an embryological enkatarrhophy is most prone 
to take place where the most complicated tissue-changes occur in the 
embryo, as about the orbit, the genital organs, and the muco-cutaneous 
junctions. Some of the cells remain in a state of incomplete differen- 
tiation for a long time even in man, as shown by the development of 
the teeth, the thymus, the mammary gland, the organs of generation, 
the bones, etc. These and many other facts prove the possibility of 
tissues remaining in a dormant condition for variable periods, and then 
assuming, under the influence of an increased physiological or patho- 
logical stimulus, renewed activity, growth, and development. During 
a certain time of the life of the individual, or in consequence of acquired 
pathological conditions, cells may arise where they have no legitimate 
existence, or at a time when they ought not to be produced, or to an 
extent beyond the physiological limits. In this manner monstrosities 
and malformations are produced in the embryo, and later tumors are 
formed from such latent imperfectly specialized tissue under the same 
conditions. We know that certain organs up to the time of puberty 
remain to a certain extent in a dormant condition, not keeping pace 
with the general growth of the body ; but when the period of puberty 
arrives, the genital organs, the mammary gland in the female, the skin 



26 PATHOLOGY AND TREATMENT OF TUMORS. 

and its appendages, are suddenly stimulated by a physiological impetus 
which results in increased tissue-growth. In pathology the proof of 
the correctness of this assertion is based on the fact that during this 
period are prone to appear certain epithelial tumors which are seldom 
met with before the age of puberty or late in life. There is no fact 
better established in pathology than that during this time of life, charac- 
terized by the highest degree of post-natal tissue-activity, the intrinsic 
capacity of cell-production in an epiblastic matrix of cells is suddenly 
aroused, and the new tissue thus produced results in the formation of an 
epithelial tumor. It is during this time of life that we most frequently 
meet with dermoid cysts in their favorite localities, branchial cysts, and 
adenoma of the breast. We have reason to believe that many persons 
the possessors of the essential tumor-matrix of congenital or post-natal 
origin fail to become the subjects of a tumor either from an insufficient 
intrinsic capacity of cell-growth and reproduction on the part of the 
latent cells composing the matrix, or owing to an inadequate degree of 
local or general stimulation. Under such circumstances the cells of the 
matrix remain permanently in a latent condition. 

A general excess of embryonic tissue under favorable post-natal 
conditions gives rise to general giant growth. Localized excess repre- 
senting the different tissues of a part or an organ results in local giant 
growth. Friedberg observed a case where, in a female child at the 
time of birth, the right leg was considerably larger than the left ; after 
birth symmetrical development failed to take place, and the larger limb 
assumed giant growth, which fact induced Friedberg to assert that giant 
growth is not only congenital, but progressive. If an excessive amount 
of embryonic tissue is present at the time of birth, giant growth may 
take place at any subsequent period during life, awaiting a favorable 
opportunity until an increased afflux of blood to the part results in 
increased tissue-proliferation, the asymmetrical growth being due essen- 
tially to the amount of embryonic tissue originally stored up in the part. 

Abnormal additional centres of embryonic tissue in the embryo 
result in all kinds of monstrosities, parasitic fetuses, supernumeraiy 
fingers and toes, accessory glands, etc. A defective amount of build- 
ing material in the embryo is responsible for many of the fetal defects, 
such as hare-lip, cleft palate, absence of or defective limbs, etc. 
Another familiar instance substantiating the correctness of the theory 
of the origin of tumors from a matrix of embryonic cells is furnished 
by the pregnant uterus. As a rule, hypertrophy of tissue is attended 
and produced by increased physiological function. In the gravid uterus 
there is an increase of muscular tissue attending simply an increased 
physiological growth of an organ, unattended by a corresponding 



ORIGIN AND NATURE OF TUMORS. 2J 

increase of function, but preparatory to a sudden emergency requiring 
great functional activity. During pregnancy the muscular fibres re- 
main in a condition of rest during the intervals between slight mus- 
cular contractions first observed and described by Braxton Hicks. 
The uterus receives an unusual blood-supply. We can explain the 
attending muscular hyperplasia only by assuming the presence of a 
superabundant deposit of embryonic cells awaiting a favorable oppor- 
tunity to develop into mature, functionally-active muscular tissue. 

The origin of a tumor from post-natal embryonic tissue is suscep- 
tible of a satisfactory explanation. Every surgeon can recall instances 
of the development of tumors from inflammatory products — scar-tissue 
and immature callus. We must take it for granted that in such tissue 
cells or groups of cells have failed to undergo transformation into 
mature tissue, and that they perform in the production of tumors the 
same role as the congenital matrix of embryonic cells of Cohnheim. 
In the absence of a more plausible theory, the writer is forced to 
conclude that every tumor is the product of tissue-proliferation of a con- 
genital or post-natal matrix of embryonic cells, aroused into activity by 
a general or local physiological stimulation or by congenital or acquired 
abnormal conditions in its immediate environment. 



II. MORPHOLOGY AND MULTIPLICATION 
OF TUMOR-CELLS. 

Morphology. — The shape of a tumor-cell corresponds very closely 
to that of the cells of the organ or part in which the tumor originated. 
In the growth of a tumor the cells retain their original type. The 
development of the cells of benign tumors ultimately reaches the 
highest degree of perfection, so that under the microscope it is difficult 
if not impossible to distinguish between tumor-tissue and the tissue 
to which it belongs or which it represents. The macroscopical and 
microscopical resemblance between a lipoma and normal fatty tissue and 

an adenoma and normal glandular tissue 
is often almost perfect. The cells of 
which malignant tumors are composed 
do not attain maturity; consequently they 
resemble more closely the fixed tissue- 
cells in their juvenile state. From the 
illustration showing the shape of young 
connective-tissue cells (Fig. 2) and sar- 
coma-cells, it will be seen that their 
morphology is more nearly identical than 
would be expected from the difference in 
their source and the accomplishment of the ultimate object of their 
existence. The most striking difference between a sarcoma-cell and an 
immature connective-tissue cell under the microscope is the size and 
number of the nuclei. The nucleus of the sarcoma-cell is large and 
often multiple, showing greater vegetative activity as compared with the 
mononucleated connective-tissue cell. Absence of uniformity of size 
in the sarcoma-cells is another distinguishing criterion. 

Most of the older text-books on pathology contain elaborate 
descriptions of a morphologically specific cancer-cell. The application 
of this teaching in practice resulted in many mistakes in diagnosis by 
placing too much reliance upon the morphological appearances of cells 
under the microscope. It is stated above that the structure of the cells 
of benign tumors is so closely akin to that of the normal cells of the 
part which the tumor represents that the microscope alone cannot be 
relied upon in distinguishing between the pathological product and the 

28 




Fig. 2. — Embryonal connective tissue: 
the intercellular substance is only slightly 
differentiated (after Piersol). 



MORPHOLOGY OF TUMOR-CELLS. 



29 



normal tissue. This assertion will be strengthened by illustrations rep- 
resenting a non-malignant epiblastic tumor and the middle strata of the 
epidermis. 




A«ro 




Fig. 3. — Cells from a spindle-celled sarcoma treated fresh in a solution of sodic chloride ; X 250 (pfter Perls). 

In carcinoma, the malignant tumor of the epiblast and hypoblast, 
the cells again bear a great resemblance to the cells which compose 
the respective germinal layers. Like sarcoma-cells, they do not attain 
maturity ; consequently they present in their structure more the type 



1 m 



&Sf% 




^^H- 



Fig. 4. — Prickle-cells from papilloma of skin; 
X 250 (after Ziesing). 



p>:^ 



Fig. 5.— Prickle-cells from middle strata 
of the epidermis (after Piersol). 



of embryonic than mature epithelial cells. In contradistinction to the 
normal epithelial cells, we find that many of the carcinoma-cells are 
polynucleated. The caudate prolongation of many of the cells is not 
a characteristic feature of a malignant epithelial cell, as was formerly 
supposed, but is one of the results of rapid cell-growth and pressure 



3° 



PATHOLOGY AND TREATMENT OF TUMORS. 



from without. The polymorphism of the cells of malignant tumors is 
largely due to the combined effect of these two factors in modifying 
cell-form. The student should remember also that the contour of a 
cell under the microscope will depend greatly on the direction of the 
cutting in making the sections. Thus if, in case of a spindle-celled 




Fig. 6. — Cells from an epithelial carcinoma of the bladder ; X 250 (after Perls). 

sarcoma, the section is made in the direction of the long axis of the 
cell, the cell will present a spindle-shaped appearance ; on the other 
hand, if the cell is cut transversely, it will present an oval outline or 
will appear round, as in cases of round-celled sarcoma. In conclusion, 
it must be said that while polymorphism and multiple large nuclei 
strongly point toward the malignant character of cells, these conditions 
cannot be relied upon in making a positive distinction between normal 
and benign and malignant tumor-cells. 

Karyokinesis. — It is now generally conceded that every patholog- 
ical process has its physiological prototype. Cell-multiplication in 
disease may arise at a place where it is not needed, or at the wrong 
time, or to an extent beyond the limits of local normal requirement. 
Tumor-cells multiply, like most of the normal tissue-cells, by indirect 



MORPHOLOGY OF TUMOR-CELLS. 31 

division, a process called karyokinesis. This is the method of repro- 
duction of nearly all the fixed tissue-cells of a higher type in the 
body. This method of cell-segmentation was first described and care- 
fully studied by Flemming, who termed the process karyomitosis. The 
essential constituents of a cell are the protoplasm and the nucleus. 
There is a strong tendency at the present time to refer all kinetic 
changes in the cell-contents to the agency of the nucleus, and to ascribe 
to the protoplasm the passive role of a nutritive substance. In the 
impregnated ovum influences of nuclear changes have been described, 
but at the same time it was shown that the protoplasm is capable of 
automatic as well as responsive action. Pfliiger thought that gravita- 
tion is the sole guiding factor in segmentation. According to Born, 
Hertwig, Weismann, and Kolliker, the protoplasm alone is isotropic, 
but Whitman thinks that this is far from the truth. Others, like Pfliiger, 
believe that the protoplasm contains physiological molecules from which 
organs are developed. Polarity of the protoplasm and the nucleus 
exists independently, and is not reciprocal. Contractions in the unfer- 
tilized eggs have been observed. The protoplasm is an active rather 
than a passive structure. M. Nussbaum was the first to establish the 
important fact that enucleate pieces of an infusorium are incapable of 
regenerating lost parts, while nucleate fragments soon regain the specific 
form. From this observation it will be seen that the nucleus is indis- 
pensable to the preservation of the formative energy of the cell, while 
the protoplasm performs an important but less essential role in the 
reproduction of cells. Nussbaum very correctly asserts that both the 
protoplasm and the nucleus are necessary in a cell to enable it to per- 
form its specific function and to reproduce its own kind. The nucleus 
does not change its form except when it is the seat of active kinetic 
changes, while the form of the cell is changeable and is greatly influ- 
enced by its environments. 

The researches of Flemming, Strassburger, Butschli, and others have 
demonstrated the great importance of the nucleus in the reproduction 
of cells. The protoplasm under the highest powers of the microscope 
is seen to consist of a fine reticulum of protoplasmic strings, the meshes 
of which contain a homogeneous fluid. The mature cell is enveloped 
by a separate cell-wall. The meshes of a similar network in the nucleus 
are filled with a granular fluid. According to Carnoy and Mayzel, the 
nucleus contains, besides, a distinctive substance called " nuclein," or, 
from its intrinsic capacity to receive and to hold coloring material, 
"chromatin." The nucleoli in mature cells are globular masses of 
chromatin, one or several in number. It is the chromatin which, when 
properly stained, outlines the figures observed during the different 



32 



PATHOLOGY AND TREATMENT OF TUMORS. 



stages of the kinetic process. The kinetic process is divided into stages 
differently. Thus, Klebs makes four, while Strassburger describes the 
process as consisting of three stages: (i) Prophase; (2) metaphase ; 
and (3) anaphase. During the first stage the nuclear chromatin arranges 
itself in the form of an oval mass. The metaphase is the stage of the 
equatorial crown when the nuclear spindle has an equatorial accumula- 
tion of chromatin fragments. During the last stage the nucleus and 
the protoplasm of the cell are divided into two symmetrical halves and 
complete the segmentation. Karyokinesis of the nucleus without 
division of the protoplasm of the cell results in multinucleated and 

A B 













Fig. 7. — Cells from the epidermis of very young larva of newt (after Piersol) : A, resting nucleus ; B, close 
skein ; C, loose skein ; D and E, mother-stars, seen from the polar field and appearing as the wreath stage ; 
F, mother-star from the side ; G, migration of segments ; H, daughter-stars ; / and J, segments grouped 
about new polar fields (in J this protoplasm exhibits constriction) ; K, daughter-skeins (division of nucleus 
complete, with slight constriction of cell-body) ; L, completed division of nucleus and protoplasm. 



giant cells. This incomplete karyokinesis frequently occurs in the 
cells of malignant tumors. The different karyokinetic figures are well 
shown in Figure 7. Cell-division by karyokinesis is called by Williams 
agamogcncsis, in contradistinction to sexual reproduction, which he 
terms gamogcncsis. In slowly-growing benign tumors new cells are 
added to the growth by karyokinesis ; in stationary tumors the cells 
lost by degeneration are replaced by the same process ; while in malig- 
nant tumors the karyokinetic process assumes great activity, resulting 



MORPHOLOGY OF TUMOR-CELLS. 



33 



in rapid growth and imperfect development of the cells. Karyokinesis 
in malignant tumors has received the careful attention of pathologists, 
and passes through the same phases as in the reproduction of normal 
tissue. In the centre of Figure 8 is seen a nucleus in which segmen- 
tation is nearly completed, while other nuclei represent incipient kinetic 








IT! v 



&<£$& 

V& 







J^w' 



Fig. 8. — Nuclear division in the epithelial cells of the skin in Paget's disease of the nipple ; X 8oo (afier 
Karg and Schmorl). The deepest section of the picture represents, in the form of a small segment, the cutis 
infiltrated with leucocytes. After this follows the epidermis with its basal layer of cylindrical cells. The 
epithelial cells show different stages of nuclear division. Large nuclei are seen in the incipient stage of seg- 
mentation, surrounded by a light zone. In the centre of the field is a mass of chromatin threads in the stage 
of star-formation. Several chromatin loops have been separated from the dividing nuclear mass. The neigh- 
boring cells have been pushed sidewise. To the left and above, daughter-star with beginning constriction of 
the nuclear body. The threads of the achromatic figure are indicated. (Fixation and hardening in sublimate 
and alcohol ; hsematoxylin staining.) 



changes. It is natural to suppose that such speedy and frequently 
imperfect karyokinesis would give rise to rapidly-growing, planless 
growths characterized by their early invasion of adjacent tissue, gen- 
eral dissemination, and an intrinsic tendency to destroy the life of the 
patient. 



III. ANATOMY AND BIOLOGY OF TUMORS. 



The life-history of tumors is of great interest to the pathologist and 
of the utmost practical importance to the surgeon. The student must 
become familiar with the influences which favor and retard tumor- 
growth before he can formulate a correct clinical distinction between 
the different varieties and outline a rational course of treatment. In 
the preceding sections we have studied the origin and growth of the 
parenchyma of tumors. We traced the tumor-cells to their original 










Fig. 9. — Channel polypus of cervix uteri ; X 5° (after D. J. Hamilton): a, fibro-cellular stroma of tumor; 
b, a gland of uterine mucous membrane ; c, a channel ; d, lining of columnar epithelium. 

source and showed their manner of reproduction in the body. Before 
considering the biology of tumors it will be necessary to discuss a few 
of the more important points in their anatomy. The essential part of 
a tumor is its parenchyma ; it is this which imparts to a tumor its ana- 
tomical characteristic and its clinical significance. The cells of a tumor 
are always limited by or imbedded in a stroma of connective tissue. 
34 




ANATOMY AND BIOLOGY OF TUMORS. 35 

In Figure 9 is shown an adenoma of the cervical canal of the 
uterus in which the essential tumor-elements, columnar epithelial cells, 
are attached to and limited by a powerful stroma of connective tis- 
sue. This picture affords a good 
illustration of the relation of the 
tumor-cells to the stroma in benign 
tumors of the epiblast and hypo- 
blast. In malignant and mesoblastic 
tumors the parenchyma appears as 
an interstitial product, the cells being 
enclosed on all sides by the stroma. 
The stroma or reticulum of a tumor 
is always derived from the meso- P P -t t A c , r , 

j ».v. inv-o^/ y JG 1Q — t ibro-chondroma from capsule of knee : 

blast, and Consists Of Some form X 4°° < after D - J- Hamilton) : a, cartilage-cells; 
r ... b, the matrix. 

01 connective tissue in greater or 

lesser abundance (Fig. 10). In epiblastic and hypoblastic tumors the 
tissue reaches the tumor from the base ; in mesoblastic tumors it fur- 
nishes a framework for the tumor on all sides. 

Blood-vessels. — A tumor is nourished by the blood-vessels which 
supply the part or organ in which the tumor is located (Fig. 11). The 
blood-vessels constitute an important part in the structure, character, 
and life-history of a tumor. The vascularization of a tumor usually takes 
place by the formation of new blood-vessels from pre-existing vessels 
in its immediate vicinity by a process of budding. A more atypical 
blood-supply is sometimes procured by canalization of cells and the 
entrance of blood into pre-existing hollow spaces or into connective- 
tissue channels entering into communication with neighboring blood- 
vessels. Most of the tumors contain a complete vascular system ; that 
is, one or a number of arteries enter it from the periphery and divide 
into smaller branches, which terminate in a network of capillaries from 
which the blood is returned to the general circulation through veins. 
The blood-vessels follow the connective tissue of the stroma, and in 
very soft and cellular tumors the}- often come in direct contact with 
its parenchyma (sarcoma). The structure of the walls of blood-vessels 
is often very defective, especially in soft and rapidly-growing sarcoma. 
Great vascularity of a tumor usually indicates rapid growth and imper- 
fect development of the parenchyma-cells of the tumor. Perforation 
of the walls of the blood-vessels by the tumor-tissue, especially the 
veins, is often observed in malignant tumors, and leads to thrombosis 
or embolism, or both of these complications may occur in rapid suc- 
cession. 

Lymphatic Vessels. — The existence of lymphatic vessels in tumors 



36 



PATHOLOGY AND TREATMENT OF TUMORS. 



was first discovered by Van der Kolk, who, as well as Krause, found 
them in carcinoma (Fig. 12). Liicke and Klebs attempted to inject the 
lymphatics of carcinoma of the lip before the extirpation of the tumor, 
but did not succeed in accomplishing the desired object. The benign 
growths are scantily, if at all, supplied with lymphatics. In carcinoma 
they are undoubtedly always present — a fact which explains on an 




Fig. 11. — Blood-vessels of tumors (after Liicke) : a, vascular injection in an osteoid chondroma; b, 
reticulum of veins from a sarcoma of the parotid; c, capillary network from a fibroma of the abdominal 
wall ; d, same from a very vascular myeloid sarcoma of the lower jaw ; e, vascular network from a carcinoma 
of the tonsil ; /, alveolar vascular network from a carcinoma of the breast ; g, injected preparation from a 
carcinoma of the lip. 



anatomical basis the manner of regional dissemination which is so con- 
stantly observed during the clinical course of this tumor, irrespective 
of its anatomical location. 

Nerves. — But little is known concerning the innervation of tumors. 
In the myelinic variety of neuroma the production of new nerve-fibres 
has been demonstrated. The tenderness and the spontaneous pain 



ANATOMY AND BIOLOGY OF TUMORS. 



37 



which belong to certain varieties of other tumors would suggest the 
presence of new nerve-fibres, and should induce pathologists to make 
additional researches relative to the nerve-supply of tumors. The want 
of proper innervation undoubtedly determines largely the planless 
growth of tumors. 

Biology. — The life-history of a tumor is greatly influenced by the 
inherent formative capacity of its cells as well as by the. general condition 
of the patient. Cells endowed with maximum reproductive power are 
always found in rapidly-growing malignant tumors, and the same type 
of tumor grows with variable speed and attains unequal size in differ- 
ent individuals during the same length of time. In certain individuals of 




Fig. 12. — Lymphatic vessels from a fungous carcinoma of the region of the hip-joint of a young man 
(after W. Krause) : a, lymphatic vessels of subcutaneous tissue which was attached to the stroma of the car- 
cinoma; b-d, lymphatic vessels from the stroma of the carcinoma itself, which communicated with the 
vessels of the subcutaneous tissue ; at b a lymphatic vessel projects beyond the level of the section. 



the same age, living under apparently similar conditions, a fatty tumor 
may not exceed the size of a walnut after a lapse of twenty years, while 
in another person it may reach colossal dimensions in a much shorter 
time. This difference in the rapidity of growth of benign tumors can- 
not be explained upon any known physiological or pathological laws. 
Some of the benign tumors grow to a certain size, and then remain 
stationary permanently or for an indefinite period of time, when, under 
certain local or general acquired causes, there again takes place active 
tissue-proliferation, which often assumes a much more active phase 
than during the first stage of tumor-growth. It has been observed by 
Liicke and others that pregnancy plays an important role in the etiology 
and growth of tumors. This influence is particularly well marked in 



38 PATHOLOGY AND TREATMENT OF TUMORS. 

tumors of the uterus and its appendages and in tumors of the breast — 
that is to say, tumors in organs the seat of prolonged and irregular con- 
gestions during pregnancy and lactation. Age influences the type and 
location of tumors. Benign tumors occur most frequently in young 
persons, while carcinoma attacks in preference persons past middle age. 
Sarcoma manifests no such predilection for senile tissue. Benign tumors 
grow more rapidly in the young than in the aged, and malignant tumors 
manifest a greater degree of malignancy in children and young adults 
than in persons advanced in years. Clinical experience has shown that 
acute infective diseases exert a retarding influence upon the growth of 
tumors. A tumor composed almost exclusively of parenchyma-cells 
is more prone to undergo early degenerative changes than is a tumor 
in which the stroma predominates. The growth of all tumors requires 
an adequate quantitative and qualitative blood-supply. The importance 
of this requirement in furthering the growth of a tumor is well shown 
by the tumors so frequently met with during the age of puberty — 
dermoid cysts. The growth of these cysts is determined by an 
increased physiological activity of the entire organism — and more par- 
ticularly of the skin, its appendages, and the organs of generation — 
which is initiated at that time. The increased physiological blood- 
supply to special organs during this time of life explains the frequency 
with which we meet with dermoid cysts of the ovary, the face, the 
base of the tongue, and the neck in young adults. To determine the 
growth of a tumor it is not only necessary to have an adequate blood- 
supply, but the blood itself must contain the nutritive and chemical 
ingredients necessary for the formation of the different kinds of tumor- 
tissue. In the development of an osteoma it is not only necessary to 
have present an embryonal matrix of indifferent bone-cells, but the 
blood must also bring to the part during the growth of the tumor the 
proper constituent elements (the earthy salts) which enter into the 
formation of bone. So, likewise, in a case of lipoma it is not only 
essential to have present an adequate quantitative blood-supply, but the 
quality of the blood brought to the tumor must be such as to produce 
fat instead of connective tissue or bone. 

An increase of blood-supply favors tissue-growth, and we can trace 
this increased vascularization in connection with tumor-growth either 
to a physiological increase or as one of the consequences of antecedent 
pathological conditions. The increased physiological blood-supply is 
either general or local. The general increase gives rise to giant growth, 
which consists in hyper-production of normal histological elements 
throughout the entire body; local increase of physiological blood- 
supply leads to local hyperplasia, localized giant growth, which may 



ANATOMY AND BIOLOGY OF TUMORS. 39 

implicate an entire organ or limb. Anything which in the organism 
will determine an increased physiological blood-supply to a pre-existing 
tumor-matrix favors tumor-growth — an assumption well established in 
cases of tumors of the breast commencing during pregnancy or lactation, 
at a time when the organ receives a largely increased supply of blood, 
which increase cannot fail in exerting a potent influence in stimulating 
cell-proliferation from a latent matrix. So, in cases of uterine tumors, 
the periodical recurrences of congestion in the affected parts during 
menstruation create a condition which accelerates tissue-growth. Con- 
sequently, myofibroma of the uterus almost without exception makes 
its appearance during the childbearing period of life, and its further 
growth is usually arrested with the cessation of menstruation. Sur- 
geons have utilized this clinical fact, and have adopted a therapeutic 
resource which aims at diminishing the increased physiologial blood- 
supply to this organ by suspending artificially this periodical function 
by the removal of the ovaries and the Fallopian tubes in the treatment 
of some forms of myofibroma of the uterus. 

A tumor frequently presents to the naked eye an appearance of 
abnormal vascularization characterized by an increased circulation, 
either arterial, venous, or capillary, as the case may be, according to 
its anatomical location or the peculiarity of the structure of the new 
blood-vessels in the tumor-matrix or its immediate vicinity. The most 
striking example of atypical vascularization is furnished by tumors 
which present pulsation as one of their most conspicuous clinical 
features. By a pulsating tumor we understand, clinically, a tumor in 
which to the usual evidences of tumor-formation are added the pathog- 
nomonic symptoms of aneurysm. In such instances many of the larger 
new blood-vessels are either entirely devoid of a proper vessel-wall, or, 
when this is present, it is defective, forming irregular cavities or spaces 
into which the blood enters from some adjoining vessel, returning either 
in the same direction or emptying into another channel. This peculiar 
structure and arrangement of vessels in many sarcomatous tumors 
would explain the frequency with which pulsation can be felt in ex- 
amining them, more especially if they have their starting-point in the 
interior of a bone. Such tumors are noted for their rapid growth, and 
have repeatedly been mistaken for aneurysms. 

Local irritation increases tumor-growth. Tumors located upon the 
surface of the body or in other parts exposed to irritating influences 
grow, as a rule, more rapidly than tumors occupying more protected 
localities. The application of irritants, such as iodine, blisters, and 
stimulating ointments, liniments, and plasters, produces the same effect. 
The same can be said of exploratory punctures and parenchymatous 



[O PA THOLOG Y AND TREA TMENT OF TUMORS. 

njections. The incomplete destruction of a malignant tumor by 
;austics is invariably followed by more rapid growth of the tumor- 
■emnants, extensive regional infection, and early general dissemination. 

Relation of Tumors to Adjacent Tissues. — The tumor-tissue is 
produced exclusively from the matrix of embryonic cells from which it 
iarted ; the adjacent tissues take no active part in the growth of tumors. 
The adjacent tissues are acted upon by the tumor, but take no part in 
ts development. The benign tumors pusli the tissues aside or apart to 
nake room for themselves ; the malignant tumors, particularly carci- 
loma, infiltrate the surrounding connective tissue and include it as a 
emporary passive constituent of the tumor-mass. The pre-existing con- 
lective tissue under such circumstances is subsequently destroyed and 
emoved by the tumor-tissue. Sarcoma follows connective tissue, nerve- 
iheaths, and blood-vessels ; carcinoma invades the lymphatics, and it is 
hrough them that regional dissemination takes place. A tumor always 
:nlarges in the direction offering the least resistance. One of the con- 
tent effects of tumor-pressure is atrophy of the tissues exposed to 
)ressure. Pressure-atrophy of the adjacent tissues is most certain to 
>ccur, and is most marked if the tumor is anatomically so located that 
ts increasing size meets with great resistance. An ordinary sebaceous 
:yst of the scalp or a dermoid cyst above the orbit, although of slow 
jrowth, often produces by atrophy a cup-shaped depression in the 
mderlying bone. A lipoma of great size occupying the panniculus 
idiposus produces little if any pressure-atrophy, because the tumor 
neets with little or no resistance to its outward growth. The pressure 
)f a tumor upon a nerve often causes intense pain, and may eventually 
lestroy its function. Prolonged compression of a large artery may 
esult in the formation of a thrombus and the complete obliteration of 
l vessel. A carcinoma or a sarcoma may destroy the wall of a large 
Lrtery, such an occurrence becoming often the immediate cause of 
leath from hemorrhage. At other times a false aneurysm is estab- 
ished in the same manner. 

Perforation of a vein by malignant tumors, preceded or followed by 
hrombosis, will be alluded to farther on as one of the many compil- 
ations of carcinoma and sarcoma. Serious and often fatal complica- 
ions may arise from the compression of an important internal organ 
>y a tumor. Thoracic and mediastinal tumors frequently destroy life 
>y causing compression of the heart, the lungs, or the large blood- 
vessels. Abdominal tumors of large size often result in death from 
narasmus by interfering with digestion. Tumors impacted in the pelvis 
nay cause retention of urine, compression of the ureters, and intestinal 
)bstruction. 



ANATOMY AND BIOLOGY OF TUMORS. 41 

Benign tumors frequently appear multiple primarily or in slow suc- 
cession ; malignant tumors, while primarily multiple only in exceptional 
cases, give rise to secondary tumors in the same region or in distant 
parts. It can therefore be asserted, as a rule, that primary multiplicity 
would indicate a benign character of the tumors, while secondary 
multiplicity is almost an infallible evidence of the malignant nature of 
the primary tumor. 



IV. PATHOLOGY OF TUMORS. 

The form of a tumor depends largely upon its location and on 
the structure of the tissues in its immediate neighborhood. A tumor 
developing from a surface and projecting beyond it, with a wide 
base, is said to be " sessile." If the tumor becomes more prominent 
and the base narrows, a pedicle forms, when it is called a " pedun- 
culated " tumor. Such tumors attached to a mucous membrane are 
usually described under the term " polypus." If a tumor originates 
from a part surrounded by tissues offering the same degree of resist- 
ance, it usually assumes a globular or an oval shape. If it occupies 
a locality covered in by a broad resisting structure, it becomes flattened 
out, as is the case with intra-articular lipoma, called lipoma arborescens. 
Unequal resistance over the surface of the tumor moulds it in all 
imaginable shapes. The surface of the tumor may be smooth, lobu- 
lated, or nodular. Benign tumors are usually smooth ; lipoma is often 
lobulated ; sarcoma is either smooth or lobulated ; carcinoma is nodular. 
The density of a tumor depends on its structure, the character of the 
tissues in its immediate vicinity, and the degenerative changes that have 
taken place. A tumor composed largely of parenchyma-cells is usually 
soft ; tumors supplied with a well-developed stroma are hard ; a tumor 
composed almost exclusively of blood-vessels (angioma) is greatly 
reduced in size under pressure ; a tumor with liquid contents (cyst) 
ordinarily presents fluctuation ; a solid but soft tumor (lipoma and sar- 
coma) is often mistaken for a cyst or an abscess, because on palpation 
a sense of fluctuation can be felt (pseudo-fluctuation). The color of 
tumor-tissue is greatly influenced by its vascularity, the character of 
the cells of which it is composed, and the extent and nature of the 
degenerative changes which have taken place. Most of the benign 
mesoblastic tumors present a whitish appearance. Sarcoma, as its name 
indicates, resembles on section flesh. The cut surface of a firm carci- 
noma is very similar in appearance and density to a raw turnip. Fatty 
degeneration of the contents of the alveoli imparts to the cut surface 
of the tumor a yellowish tinge. Hemorrhage into the substance of a 
tumor produces pigmentation of various degrees, from almost black to 
a yellow tinge. The black color of melano-sarcoma and melano-car- 
cinoma is a distinguishing feature of these forms of malignant tumors. 

42 



PATHOLOGY OF TUMORS. 



43 



Tumor-tissue, stroma and cells, is subject to the same pathological changes 
as the normal tissues of the body. Among the more important of 
these changes are the regressive metamorphoses of the cellular elements. 
Fatty Degeneration. — Fatty degeneration of the parenchyma-cells 
of a tumor is one of the most frequent secondary pathological changes 
observed in tumors. The immediate cause of this form of degeneration 
is a defective blood-supply ; hence it occurs most frequently in old 
benign tumors and in malignant tumors in which vascularization does 
not keep pace with the increase of tissue. It is a constant occurrence in 
slowly-growing carcinoma of the lip and the breast. In ulcerating sur- 
face epithelioma the fatty material can be squeezed out from the alveoli 
in yellowish-white masses resembling the contents of a small retention- 
cyst of the sebaceous glands. In glandular carcinoma the alveoli which 
have undergone this change present themselves on the cut surface as 
yellow areas of variable size, from which the same kind of material 
escapes under pressure. If this material is examined under the micro- 






FlG. 13.— Fat-crystals; X 250 (after Perls). 



scope, nothing but a granular detritus can be seen, with here and there a 
fat-crystal (Fig. 13) or a cholesterin-plate (Fig. 14). The fatty change 
commences as an infiltration of the cells, this infiltration finally resulting 
in the breaking up of the cells into granular matter. The distinction of 
cells by this or by any other form of regressive metamorphosis retards 
tumor-growth ; but while the growth has become stationary at one place 
it continues in other places, so that a tumor is seldom entirely removed 
by degenerative changes. Degeneration commences either in the oldest 
part of the tumor or in parts of it which by accident have been deprived 
suddenly or gradually of an adequate blood-supply. It is upon this 
well-known and thoroughly established pathological fact that surgeons 



44 PATHOLOGY AND TREATMENT OF TUMORS. 

have made an attempt to imitate and anticipate the natural forces 
which tend to limit or to arrest tumor-growth by cutting off the blood- 
supply from the part, as suggested by Wolfler in the treatment of 





Fig. 14. — Cholesterin-plates ; X 2 5° (after Perls). 

tumors of the thyroid gland, and by gynecologists in ligation of the 
uterine arteries in the treatment of non-malignant tumors of the uterus. 
Mucoid Degeneration. — The transformation of active tumor-cells 
into a harmless, innocent mucoid substance has been observed in tumors 
belonging to the connective-tissue type, fibroma and 
chondroma, and also occasionally in adenoma. The 
part of a tumor which undergoes this form of degen- 
eration becomes cystic. 

Colloid Degeneration. — The exact chemical com- 
position of colloid material has not been determined. 
Scherer regards it as an albuminous substance in 
combination with a carbohydrate analogous to mucin 
and metalbumin. Colloid material is a jelly-like, 
structureless substance derived by a degenerative 
process from the parenchyma-cells or the stroma of a tumor. This 
form of degeneration takes place in both benign and malignant tumors, 
but is observed most frequently in tumors of the thyroid gland, of the 
ovary, and of the gastro-intestinal canal. If the parenchyma-cells 
undergo this change, the colloid material appears in the protoplasm 
of the cell at one or different points, and the process continues until 
the cell-walls give way, when the colloid material is liberated (Fig. 15). 



Fig. 15.— Colloid de- 
generation of the epithe- 
lial cells of a cancerous 
tumor of the mamma ; 
X 400 (after D. J. Ham- 
ilton). 



PATHOLOGY OF TUMORS. 



Plate i. 











wf»P;|, 'Jam 



PI 







". « - I 









> "■- ..-.>i6© 



A# 3P 




*.*& 



* 4 ■; 



6 s 



S E 

- C 



o E 



E u 



PATHOLOGY OF TUMORS. 45 

Colloid cysts of the ovary often attain a colossal size, and abdominal 
surgeons are well aware of the fact that such cysts are prone to 
return even after what seemed a thorough removal of the tumor. 

Amyloid Degeneration. — The transformation of tumor-cells into 
a starchy substance takes place most frequently in the cells of malig- 
nant epiblastic tumors, also in secondary carcinoma of the lymphatic 
glands. We have no positive knowledge concerning the true nature 
of the corpora amylacca found in certain tumors as one of the many 
degenerative changes, and in other pathological products. It is un- 
doubtedly an albuminate, as its micro-chemical actions correspond with 
those given by other albuminates. This substance has never been 
detected in the blood ; it is therefore reasonable to suppose that it is 
formed in the places in which it has been found. In a specimen of cyst 
of the choroid plexus in the museum of Rush Medical College numer- 
ous corpora amylacea were found in close proximity to a large blood- 
vessel (PI. I., Fig. 1). The degeneration of an adenoma into a colloid 
substance imparts to the tumor an entirely new aspect, transforming it 
from a solid into a cystic tumor. 

Hyaline Degeneration. — The product of hyaline degeneration dif- 
fers from the amyloid substance in that it does not give the reactions 
to iodine. The hyaline substance in tumors appears either alone, when 
the entire tumor has undergone degeneration, or in circumscribed places 
surrounded by the cells or stroma of the tumor. It is found in benign 
and malignant tumors of all germinal layers. Tumors in which this 
change was marked have been called by different names — tumeurs 
heteradeniques (Robin) ; Schlauchknorpel-geschwulst (V. Meckel) ; 
cylindroma (Billroth) ; Schleim-cancroid (Forster) ; Schlauch-sarcom 
(Friedreich) ; siphonoma (Henle). Thiersch insisted that such tumors 
do not represent a special clinical or anatomical variety, but are tumors 
in which parts have undergone regressive metamorphosis. Hyaline 
degeneration in other pathological products attacks in preference the 
small blood-vessels, and it is more than probable that when it occurs 
in tumors it begins in the same place and extends from the blood- 
vessels to the stroma or the parenchyma-cells. Hyaline degeneration 
most frequently attacks endothelial structures, but it extends into the 
connective-tissue spaces where the hyaline substance is deposited, as is 
shown on Plate II. (Fig. 1). A very interesting tumor of the orbit, 
which tumor in all probability started from the internal angle of the 
eye, examined in the laboratory of Rush Medical College, showed very 
extensive hyaline degeneration (PL I., Fig. 2). If hyaline degeneration 
commences at the same time in several parts of the tumor, by coales- 
cence large spaces are formed in which no tumor-elements can be found. 



4 6 



PATHOLOGY AND TREATMENT OF TUMORS. 



Caseation. — Local anemia is a recognized cause of caseation, but it 
remains an open question whether this form of degeneration can occur 
independently of the bacillus of tuberculosis, so that when this kind of 
metamorphosis is found in a tumor it is well to inquire into the pres- 





Fig. 16. — Petrifaction of a glioma (psammoma) of the brain ; X 250 (after Perls) : A, large laminated 
concrements ; B, calcification of capillaries; deposition of the lime-salts in the form of homogeneous 
masses. 



ence of the specific influence which is known to produce tyrosis. A 
tumor may become the seat of infection with the bacillus of tuberculo- 
sis, and the presence of this specific cause will determine the character 
of the regressive metamorphosis. It is only reasonable to assume that 
the atypical vascularization of tumors furnishes a condition favorable 



PATHOLOGY OF TUMORS. 



to localization of floating germs, and consequently constitutes one ■ 
the causes of auto-infection. 

Calcification or Cretefaction. — This degenerative process has be< 
seen in all kinds of tumors and in all the cellular elements, pare 
chyma-cells and stroma. By this process a chalky substance is su 
stituted for the tumor-tissue. 
It is usually preceded by fatty 
degeneration ; at other times it 
prepares the way for ossification 
of the tumor. It occurs fre- 
quently as a marantic change 
in the arteries and cartilage of 
the aged. The chalk)' material 
is deposited in the form of small 
granules in the tissues, taking 
the place of pre-existing degen- 
erated cells. In a normal con- 
dition the lime-salts are kept in 
solution in the tissues by organic 
acids and by free carbonic acids. 
Deposition under abnormal con- 
ditions is caused by diminution 
in the quantity of organic acids 
and free carbonic acid, by the 
existence of insoluble in place 
of soluble lime-salts, or by an 
abnormal increase of lime-salts 
reaching the affected part, result- 
ing in direct infiltration of the 
tissues. In some instances the en- 
tire tumor eventually is petrified, 
the inorganic substitute retaining 
the shape of the original tumor 
(Fig. 1 6). 

The so-called limc-mctastasis 
described by Virchow has been observed in cases of extensive disea 
of the bones, and is caused by the return into the circulation < 
the liberated lime-salts, which become deposited in distant orgar 
notably the kidneys and lungs. Petrifaction was noted in a sarcon 
of the soft tissues of the arm by Liicke. Maceration of this part < 
the specimen in an acid, examined under the microscope, reveal* 
spindle-shaped cells. Calcification frequently occurs in benign ej 




Fig. 17. — Skeleton of an ossifying periosteal sarcoma 
the femur (after Sutton). 



48 PATHOLOGY AND TREATMENT OF TUMORS. 

blastic tumors and in adenomatous tumors, particularly of the thyroid 
gland and ovary. 

Ossification. — Calcification in a tumor has frequently been mis- 
taken for ossification. We can speak of ossification only if, after the 
removal of the tumor, the specimen decalcifies and the remaining part 
exhibits under the microscope the structure of bone. Ossification of 
the tumor-cells always takes place in osteoma. It occurs also in chon- 
droma and in dermoid cysts. Periosteal sarcoma is noted for its bone- 
producing capacity. In periosteal sarcoma of the cranial, pelvic, and 
long bones we find an irregular framework of long, delicate spiculae 
of bone, the spaces filled in with sarcomatous tissue. In some carti- 
laginous and sarcomatous tumors immature bone (osteoid tissue) is 
formed in place of true bone (Fig. 17). 

Interstitial Hemorrhage and Thrombosis. — The great vascularity 
of some tumors and the imperfect structure of the walls of blood-vessels 
frequently result in spontaneous hemorrhage, or hemorrhage under 
such circumstances is produced by a slight trauma, such as a contu- 
sion, a palpation of the tumor, or an exploratory puncture. The blood 
escapes into pre-existing spaces (cysts) or is diffused through the 
stroma of the tumor or between the cells. If the hemorrhage is con- 
siderable, the tumor increases suddenly in size and becomes more tense. 
The tension thus produced is also the cause of a sudden appearance 
or increase of pain. The extravasation, if limited in quantity, is usually 
removed by absorption ; if this does not occur, it either leads to the 
formation of a cyst or determines infection of the tumor by pathogenic 
microbes. Hemorrhage always causes a change in the appearance of 
the tumor-tissue from the presence of the coloring material of the 
extravasated blood which is imbibed by the tissues. 

If the hemorrhage is profuse, the presence of extravasated blood 
in the tumor is often indicated on the surface, a few days after the 
accident, by the appearance of ecchymosis. The atypical vasculariza- 
tion of a tumor renders the blood-vessels peculiarly amenable to im- 
plication during the degenerative changes of the tumor-tissue. For 
instance, if, according to the views taught by Rokitansky, new blood- 
corpuscles form from the endothelial lining of a new closed blood-space 
by gradual growth and dilatation, this space is brought in contact with 
a vein-wall within or outside the tumor, and by a process of pressure- 
atrophy a communication is established between the pre-existing vein 
and a new blood-channel. Such an occurrence determines atypical 
vascularization of a high degree and imparts to the tumor important 
clinical and pathological features. The blood entering such spaces 
from adjacent vessels, and not meeting with normal resistance on 



PATHOLOGY OF TUMORS. 49 

account of a defective vascular wall, produces pulsation, and in many 
instances, if such abnormal vascularization exists on a large scale, there 
can be heard on auscultation a marked bruit caused by irregular dis- 
tribution of the blood in the atypical vessels. These are the cases 
described by the older surgeons and pathologists as " bone-aneurysm," 
when the disease affects the bone. A simple hemorrhagic cyst re- 
sembles one of these new blood-spaces, with or without a communi- 
cation with adjacent vessels. The new vessels in a tumor, when 
imperfect in structure and largely dilated, often become the seat of 
mural thrombosis, the irregular surface of the defective intima pre- 
senting projecting points upon which, by conglutination, the third 
corpuscles of the blood become arrested and implanted, constituting 
in the course of time a white thrombus, which, when it encroaches 
upon the lumen of the vessel or blocks it completely, gives rise to 
coagulation-necrosis in the impeded blood-current on the distal side 
or upon the surface of the white thrombus, furnishing the necessary 
conditions for the formation of a red thrombus, which then completely 
obstructs the circulation in the corresponding part of the vessel. 
Another form of thrombosis and obliteration of a vessel is met with as 
the result of perforation of the vessel-wall by a tumor, usually of a ma- 
lignant type. This accident is one of the most interesting conditions 
in the pathology and clinical history of a malignant tumor. If, for 
instance, a carcinoma attacks a vein-wall, destroying pre-existing struc- 
tures by infiltration, retrograde metamorphosis, and pressure-atrophy, 
until by perforation the tumor projects into the vein, forming a neo- 
plastic thrombus composed of tumor-tissue, when the axial blood- 
current comes in contact with abnormal tissue, that tissue being devoid 
of the physiological properties required for a normal circulation, the 
thrombus increases in size by conglutination of the third corpuscle upon 
the most prominent part of the projecting tumor-mass, the neoplastic 
thrombus serving as a foreign body in the vessel ; mural stasis of the 
white corpuscles also takes place, the conglutinated and aggregated 
corpuscular elements of the blood furnishing a most favorable soil for 
further cell-proliferation from the intravascular part of the tumor, which 
necessarily soon terminates in complete obstruction of the affected ves- 
sel. The writer has seen the internal jugular vein obstructed in its entire 
length in cases of secondary glandular carcinoma of the neck (Fig. 18). 
The neoplastic thrombus always manifests a tendency to increase in 
size by infiltration of the temporary obstructing thrombus, the blood- 
coagulum with tumor-cells, and when loose fragments become detached 
they are carried along with the blood-current, and, arriving at a point 
where the vessel is too narrow for their passage, become arrested and 



5° 



PATHOLOGY AND TREATMENT OF TUMORS. 



give rise to embolic metastasis. In some cases embolism takes place by 
the projection of the proximal end of the thrombus into the lumen of a 
larger vein ; isolated cells and small fragments, becoming detached, are 




Fig. 18. — Thrombosing carcinoma-proliferation in the left jugular vein in carcinoma at the base of the 
brain (after Ziesing): m, hyo-thyroid muscle ; g, proximal termination of inferior thyroid vein, with pro- 
jecting plug of tumor-tissue ; e and b, internal jugular vein; t, cut open, showing intravascular part of 
tumor, f; b, part of vein not laid open, and terminal part of facial vein ; a, probe in jugular foramen; d, 
carcinomatous infiltration of cervical glands. 

washed away by the blood-current : embolism in such cases establishes 
independent centres of tumor-growth wherever such tumor-infarcts 
occur, the products of tissue-proliferation at the distant points corre- 



PATHOLOGY OF TUMORS. 51 

sponding in every respect with that of the primary matrix. As in 
cases of septicemia and pyemia the emboli produce at distant points 
the same characteristic tissue-changes that are typical of the primary 
thrombus, so in cases of thrombosis and embolism in malignant growths 
the distant secondary tumor produced by an embolus from a neoplastic 
thrombus corresponds in structure and type with the primary tumor 
Thrombosis and embolism in such instances effect a transplantation 
as it were, of a part of the primary tumor to some distant part, the 
secondary tumors of embolic origin being the direct offsprings from 
the maternal or primary tumor. Dissemination of benign tumors by 
thrombosis and embolism is unknown. 

The existence of thrombosis of many veins or of a large vein within, 01 
in the immediate vicinity of, a malignant growth should be suspected bj 
the presence of cedema and enlargement of the subcutaneous veins in the 
region from which the blood is returned through the obstructed veins. Ir 
one case of complete obstruction of the entire lumen of the interna' 
jugular vein which occurred as a complication of carcinoma of the 
lower jaw with extensive glandular infection, the cedema extended tc 
the face on the same side and to the temporal region, and all the 
superficial veins were greatly distended. 

Capsule of Tumor. — All benign tumors are encapsulated ; that is. 
a well-defined connective-tissue partition is interposed between the 
tumor and the adjacent tissue, beyond which partition the tumor 
never extends. Malignant tumors are devoid of such a limiting 
boundary-line between tumor and surrounding tissues. In sarcoma 
a capsule is often found, but pathologically it is absent, because it is 
infiltrated with tumor-cells and the cells permeate it and infect the 
adjacent tissues. In carcinoma there is never even an attempt at the 
formation of a capsule. 

Lymphatic Glands. — Enlargement of the lymphatic glands in the 
region occupied by the tumor indicates one of two things: 1. The 
introduction into the lymphatic channels of pathogenic microbes 
through an ulcerating inflamed benign tumor ; 2. The transportation 
from a primary malignant tumor of tumor-cells through the lymphatic 
channels into the lymphatic glands. Enlargement of lymphatic glands 
in connection with benign tumors never occurs unless the tumor by a 
loss of continuity on the surface furnishes an infection-atrium for the 
entrance of pathogenic microbes from without. The termination of 
the complicating lymphadenitis under these circumstances will depend 
upon the number and kind of microbes that have reached the lym- 
phatic glands. Sarcoma seldom gives rise to glandular infection. Car- 
cinoma, superficial and deep, almost invariably is complicated sooner or 



52 PATHOLOGY AND TREATMENT OF TUMORS. 

later by regional infection through the lymphatic vessels and glands. 
This subject will be discussed more exhaustively in the sections on 
malignant tumors. 

Inflammation. — If inflammation occurs in a tumor, it is an unmis- 
takable proof that the tumor-tissue has become infected with patho- 
genic microbes. Infection may occur with and without a tangible 
infection-atrium. In the former case the tumor-tissue is exposed 
directly to infection by an abrasion, a cut, a puncture, or an ulcer, 
and through such defects pyogenic and other pathogenic microbes 
reach the tumor-tissue, and produce there, as elsewhere, their specific 
pathogenic effect. In the absence of such a direct port of entrance 
we must explain the occurrence of inflammation by floating microbes 
which reach the tumor with the circulating blood, and after localization 
has taken place incite inflammation in the same manner and to the 
same extent as when infection takes place through a more direct route. 
Tumor-tissue possesses a lower resisting power to inflammation than does 
normal tissue ; hence inflammation often results in extensive suppuration 
and gangrene, which in the case of benign tumors may result in a spon- 
taneous and permanent cure. Malignant tumors are often the seat of 
infection and inflammation, but there is not a single authenticated case on 
record in which a spontaneous and permanent cure was effected in this 
manner. Inflammation, as a rule, increases the malignancy of malig- 
nant tumors, and the effects produced by it increase the suffering and 
hasten death. Inflammation in a tumor is often unintentionally pro- 
duced by making an exploratory puncture without the necessary 
aseptic precautions and by making subcutaneous or parenchymatous 
injections. 

Ulceration. — Ulceration of a tumor is either the result of accident 
or it follows causes inherent in the tumor itself. In the great majority 
of cases ulceration takes place when the tumor implicates the over- 
lying skin or mucous membrane — when, either in consequence of 
pressure-atrophy or of the destruction of the skin by the tumor, a 
surface defect is produced and the tumor-tissue is exposed to direct 
infection. Sometimes, when the skin has become greatly attenuated 
by pressure from beneath, a small abrasion serves as a point of 
entrance, and the destruction of skin is hastened by an infective 
inflammation. The superficial ulcer in such cases is often the fore- 
runner of a deep phlegmonous inflammation of the tumor, followed 
by more or less extensive sloughing. Suppurative inflammation and 
abscess-formation not infrequently are the direct causes of the super- 
ficial ulceration. 

Accidental ulceration is often produced by friction on the part of 



PATHOLOGY OF TUMORS. 



53 



the clothing, by contusions and wounds, by the application of irritating 
substances, and also by incomplete operations. The clinical behavior 
of an accidental ulcer varies according to its size and the character of 
the tumor. An ulcerated surface communicating with a suppurating 
cyst by a fistulous tract will not heal until the epithelial structures 
lining the cyst-wall are destroyed by the suppurative inflammation or 
are removed with the knife or destroyed by caustics. Defects of 
benign growths caused by inflammation, by caustics, or by incomplete 
operations heal, as a rule, 
in the same manner as do 
wounds of normal soft parts 
— by granulation, cicatriza- 
tion, and epidermization. 

Spontaneous ulcers — that 
is, ulcers caused by conditions 
inherent in the tumor — are 
constantly seen on the sur- 
face of carcinoma of the skin. 
The initial defect always oc- 
curs about the centre of the 
growth, covered by a crust 
which, when removed, leaves 
a raw and often bleeding sur- 
face. A spontaneous ulcer, as 
a rule, never heals : its tend- 
ency is to enlarge. The mar- 
gins and the base present the 
firm induration so character- 
istic of this form of carcinoma. 
Ulceration of glandular car- 
cinoma is frequently followed 
by sloughing, suppuration, 
and putrefaction from the 
action of putrefactive bacilli 
upon dead tissue. The sloughing and suppuration of such a carcinoma 
usually give rise to a deep excavation in the centre of the tumor, in 
which excavation the secretions stagnate and putrefy, becoming the 
source of a sickening odor. In ulcerating sarcoma the tumor-tissue 
often projects far beyond the surface of the ulcer in the form of a 
fungous mass, the fungus licematodcs of the old authors. 

Grafting of a Malignant upon a Benign Tumor. — By the grafting 
of a malignant upon a benign tumor is meant, not the transformation 




Fig. 19. — Lipoma with a sarcoma grafted upon it (Liicke) : 
a, fatty tissue ; h, connective tissue ; c, sarcoma. 



54 PATHOLOGY AND TREATMENT OF TUMORS. 

of a benign into a malignant tumor, but the appearance of a malig- 
nant tumor in the immediate vicinity of a benign tumor. Such an 
intimate connection between a malignant and a benign tumor is shown 
in Figure 19. The occurrence of the malignant tumor in such cases 
appears purely accidental, and yet from an embryological standpoint 
a more intimate relationship in the etiology of the two entirely differ- 
ent tumors can be shown. For instance, in the specimen shown in 
Figure 19 it is evident that the lipoma sprang from a matrix of embry- 
onic cells in the panniculus adiposus, while the sarcoma had its origin 
from a similar matrix in the connective tissue of the skin. It is more than 
probable that the embryonic cells composing the sarcoma-matrix were 
arrested in their development at an earlier stage than were the embryonic 
cells in the adjoining fatty tissue ; consequently, the matrix in the skin 
gave rise to tumor-tissue of an embryonic type, while the matrix in the 
fatty tissues produced tumor-cells which possessed the intrinsic prop- 
erty to develop into mature tissue. From the illustration it can readily 
be seen that the sarcoma would eventually invade the lipoma, the tissue 
of which would yield to it in the same manner as would normal adipose 
tissue. 

In concluding this section it is proper to recapitulate that tumor- 
tissue is subject to the same degenerative changes as normal tissue altered 
by accident or hv disease, and that it constitutes a locus minoris resist- 
entiae in the event of direct or indirect infection with pathogenic microbes. 



V. TUMORS IN PLANTS AND ANIMALS. 

Before considering the etiological factors concerned in provoking 
tumor-growth it will be of interest to learn something of tumors in the 
lower animals and plants, for the purpose of showing that tumors occur 
in frequency in proportion to the complexity of the organism they 
inhabit ; that is to say, they are least frequent in plants and animals 
of a low degree of development, and most frequent in man. 

Tumors in Plants. — For the remarks on this subject the writer is 
largely indebted to the work of Mr. Williams on Cancer- and Tnmor- 
f ormation. The resemblance of tumors of the higher animal organisms 
and those of plants was pointed out by Virchow years ago. In tumor- 
formation we find kindred processes throughout the organic world. 
Each cell leads to a certain extent a parasitic existence. If it were not 
for the restraining and modifying influence exerted by the whole 
organism, each cell might develop into the form of the parental organ- 
ism. In proportion as the cells are highly specialized their primitive 
reproductive function is either greatly diminished or altogether lost. 
In the higher organism certain cells remain unspecialized. Under 
favorable conditions certain unspecialized or indifferent cells may grow 
and develop without regard to the requirements of the adjoining tissues 
and of the organism as a whole. Tumors can be studied to better 
advantage in plants than in animals. Buds may remain in a latent 
condition for years, and yet under favorable conditions their activity 
may revive. Buds may arise on any part of the plant ; in fact, wherever 
there is an excess of nutritive materials capable of being utilized for 
growth by the cells of the part, there buds arise. Under such circum- 
stances buds may be formed wherever undifferentiated cells are present. 
Vegetable tumors are produced by abnormal bud-evolution. Mr. 
Williams classifies plant-tumors into three main groups. The first group 
is represented by the discontinuous or circumscribed growths (Fig. 20), 
to which the vaguely-used term of knaurs should be restricted, and 
includes all those nodules so often met with in the bark of the beech, 
elm, oak, birch, holly, cedar, and other trees. These tumors corre- 
spond with the benign epiblastic tumors in man. The older nodules 
are generally found lying completely isolated in the bark, enclosed in 

55 



56 



PATHOLOGY AND TREATMENT OF TUMORS. 



i distinct capsule. A narrow fibro-vascular pedicle may sometimes 
je seen connecting the younger nodules with the woody tissues of the 
xunk or stem. These tumors have been traced to abnormal growths 
)f adventitious or latent buds. The writer examined the branch of a 
:edar tree which had evidently been injured, and found a tumor which 
apparently belonged to the second 
j-roup. From the tumor sprang a 
;uft of flowering branchlets entirely 
different from the remaining branches, 
it is apparent that in this instance the 
njury excited tissue - proliferation 
rom two distinct matrices, one re- 
sulting in the formation of the tumor, 
he other resulting in the production 
}f branchlets bearing the generative 
organs. 

The second group, comprising the 
:ontinuous tumors — to which the 
:erm exostosis should be restricted — 





Fig. 20. — Five circumscribed tumors in the bark 
of a holly tree ; natural size (after Williams). 



Fig. 21. — A continuous tumor (exostosis) from an 
elm tree, in longitudinal section (after Williams). 



present themselves as nodose outgrowths of the trunk or branches 
Fig. 21). The stem and branches of a tree bear a great resemblance 
n structure to the long bones. The centre or medulla corresponds to 
:he medullary canal, the wood to the bone-tissue, and the cambium 
:o the periosteum. 

Tumors belonging to this group often attain great size. Dutrochet 
attributes these growths to an excessive local cell-proliferation of the 
;ambium layer, but their connection with the woody tissue of the stem 
exists from the beginning and is never lost. Mr. Williams regards them 
is abnormally-developed branches. 

The third group is represented by growths which present a surface 
:hickly studded with shoots and stunted branches, constituting a com- 
bination of exostosis with diffuse bud-formations. The tumor of the 
;edar branch alluded to represented both the second and third groups 
Df plant tumors. The production by these growths of large quantities 
}f proliferating, lowly-organized cellular tissue which subsequently 



TUMORS IN PLANTS AND ANIMALS. 



57 



undergoes imperfect evolution constitutes the nearest approach in 
vegetable pathology to the malignant tumors of animals. Every gar- 
dener knows that injury to plants is one of the most common ways by 
which latent buds in plants can be made to develop, and he makes use 
of this knowledge in the propagation of some of the plants in which 
latent buds are most constantly found. 

Tumors in Animals. — J. Bland Sutton has done more than any 
other living author in adding to our knowledge concerning tumors in 
animals, and the writer can do no better than to quote freely from the 
chapter on this subject in his excellent book, Tumors, Innocent and 
Malignant, recently issued from the press. 

Lipomata. — Fatty tumors are rare in animals. They are found most 
frequently in the subserous adipose tissue in horses, oxen, and sheep. 




Fig. 22. — Bell's specimen of Chcztodon, with its bony tumors and large occipital crest (after Sutton). 

In stall-fed oxen excessive accumulation of fat is common in the sub- 
peritoneal tissue, especially in the omentum ; but such formations 
accompany general obesity, and do not come into the category of 
tumors. 

Ostcomata. — These are very generalized tumors ; they have been 
met with in several species of fish (Fig. 22). The bony outgrowths 
to which the term " exostosis " is applicable are of fairly common occur- 
rence in mammals, and their frequency on the bones of horses can be 
appreciated only after a visit to a veterinary museum. 

Odontomes are more frequent in animals than in man. The animals 



58 



PATHOLOGY AND TREATMENT OF TUMORS. 



in which they are found most frequently are the marmot, agouti, por- 
cupine, goat, sheep, bear, kangaroo, horse (Fig. 23), and elephant. 

Myomata. — Uterine myomata are almost unknown in mammals. 
The only specimen which came under the observation of Mr. Sutton 
occurred in a female baboon, and was rather a general enlargement of 
the uterus than an actual tumor. 

Sarcomata have the widest zoological distribution. They occur 
with very great frequency, especially the round-celled and spindle- 
celled species ; they are met with in fish, birds, rats, mice, horses, 
sheep, dogs, cats, goats, oxen, monkeys, bears, marsupials — indeed, in 
all the orders of mammals and in snakes. 

Epithelial tumors in animals, wild or domesticated, form a subject 
of great interest in its bearings on cancer and its allies. Unfortunately, 

few reliable observations pertain- 
ing to this subject are available. 
For instance, a cursory review 
of veterinary periodical literature 
would indicate that epithelioma 
of the penis is a common disease 
in bulls and horses, but a critical 
examination of the cases reported 
shows clearly enough that many 
supposed examples of epithelioma 
are, as a matter of fact, instances 
of penile warts, and all competent 
histologists who have investigated 
this subject are unanimous in as- 
serting that epithelioma of the 

-Cementome from a horse; one-half natural size penis ill hd'SeS and bulls is eX- 

(afterSutton) - ceedingly rare. Wild animals in 

a state of nature and those living in confinement appear to be abso- 
lutely free from cancer. 

Adenomata occur in domestic mammals. The bitch is especially 
liable to tumors of the mammary gland that are analogous to the large 
cystic adenomata of women. These tumors often attain an enormous 
size. Large cystic adenomata with intracystic processes are occasion- 
ally seen in the udders of cows. The mammary glands of cats are 
liable to a disease histologically identical with mammary cancer in 
women, but cancer such as attacks the human mamma is unknown 
in cows, mares, ewes, goats, or bitches. Dogs are subject to ulcerat- 
ing sebaceous adenoma in the skin around the anus, the tumor being 
prone to return after extirpation. 




TUMORS IN PLANTS AND ANIMALS. 5, 

Teratomata are common enough among domestic animals, am 
many examples have been described in fish, frogs and other batra 
chians, lizards, snakes, birds, rabbits, etc. 



Pmmmomata. 




Fig. 24 — Psammoma in the lateral ventricle of a horse's brain (after Sutton). 





Ovary. 



Fig. 25. — Frog with a supernumerary hind leg Fig. 26. — Ovarian hydrocele in a rat; natural size (after 
(after Tuckerman). Sutton). 

Cystic Tumors. — The frequency of these tumors in vertebrata gen- 
erally forms a striking contrast to the infrequency of connective-tissue 



60 PATHOLOGY AND TREATMENT OF TUMORS. 

and epithelial tumors. While true cystic tumors are rare, cystic tumors 
resulting from retention of a physiological secretion are frequently met 
with. Such conditions as hydronephrosis, congenital cystic kidney, and 
dilatations of the vitello-intestinal duct have been observed. Hydrocele 
of the tunica vaginalis is rare, because the funicular pouch in mammals 
retains its connection with the general peritoneal cavity throughout 
life. Cysts arising in connection with the central nervous system have 
been observed in foals, pigs, and calves. Hydrocephalus is fairly 
frequent, but spina bifida is rare. (Esophageal diverticulae are often 
seen in horses, and the same animal is exceedingly liable to synovial 
cysts and ganglia. 



VI. ETIOLOGY OF TUMORS. 

In the first section the writer made an attempt to prove, so far as 
present knowledge of this subject will permit, that all tumors, benign 
and malignant, have their origin from a matrix of embryonic cells of 
a congenital or post-natal origin. It remains to discuss here the influ- 
ences which enable the latent cells to assume active tissue-proliferation, 
upon which depends the production of tumor-tissue. We regard the 
matrix of embryonic cells as the essential cause of tumor-formation, without 
which all intrinsic and external exciting causes are inadequate to produce 
a true tumor. On the contrary, we must admit that such a matrix will 
remain harmless in the absence of congenital or post-natal exciting causes. 
Certain cells never become specialized to a high degree, and conse- 
quently retain their original inherent power of proliferation. Before 
discussing the influence of heredity and post-natal exciting causes ref- 
erence will be made very briefly to congenital tumors. 

Congenital Tumors. — In a certain sense the majority of tumors 
are congenital in so far as the essential matrix of embryonic cells is 
concerned. It is only in cases in which a tumor develops from a matrix 
of embryonic cells of post-natal origin that the essential tumor-matrix is 
not congenital. When we speak of a congenital tumor, however, we 
mean a tumor which is present at the time of birth. In such cases the 
tumor-matrix is acted upon during intra-uterine life by influences which 
determine tumor-formation, and the resulting product behaves clinically 
after birth in the same manner as do tumors of post-natal origin. We 
must therefore make a distinction between a true tumor and localized 
hypertrophy or giant growth at the time of birth. There are in chil- 
dren cases of " partial obesity " — cases in which the adipose tissue of a 
certain region of the body is greatly in excess of the adipose tissue gen- 
erally, and yet the characters of a tumor are wanting. Of such a nature 
is the case related by Lebert, of a female aged nineteen, the left side 
of whose abdomen was the seat of an enormous increase of fat. This 
growth began at the age of six months, and was thought to have 
been congenital ; it grew in proportion to the rest of the body, and 
ceased to grow when the girl attained puberty. Lebert calls this a 
" lipoma diffusum." In giant growth the tissues are under the influence 
of, and are controlled by, the same physiological lazes -which govern the 

61 



62 PATHOLOGY AX D TREATMENT OF TUMORS. 

growth and development of the remaining tissues of the body, lohile a 
congenital tumor recognizes and obeys no such governing influences. 
Angiomata are nearly always congenital. The tumors, although pres- 
ent at birth, are often overlooked, owing to their small size. Next in 
frequency as congenital tumors are the lipomata and cysts. Nearly 
all benign tumors may have a congenital origin. Only in very rare 
instances have malignant tumors been found and recognized as such 
at the time of birth. Ramdohr reports a case of congenital multiple 
angio-sarcoma. The body of the child, which died shortly after birth, 
showed a large angio-sarcoma in the region of the chin, and twenty-one 
secondary superficial tumors ; also sixteen metastatic tumors of the vari- 
ous internal organs. Ahlfeld reports a case of congenital fibro-sarcoma 
of the genital organs in a child three and a half years of age, and a 
case of congenital carcinoma in the distal end of an atresic rectum in 
a new-born infant. It is a significant fact that many tumors arise from 
rudimentary organs, vestiges (Sutton), or accessor)- organs — " rests " 
(Sutton) which remain functionless in the body until the time of puberty, 
when they become the starting-point of a tumor. Tumors from such 
structures seldom form during intra-uterine life, but appear later. 
Different forms of retention-cysts have been found in infants at the 
time of birth. The mechanical obstruction causing the retention is 
more often the result of a faulty development of the ducts of secreting 
organs than of other intra-uterine pathological conditions. 

Heredity. — Heredity in the etiology of tumors is a subject upon 
which much has been said and written. We no longer speak of a 
" tumor-dyscrasia," but we cannot ignore the influence of heredity in 
the origin and growth of tumors. The laws of heredity depend upon 
the persistence of impressions (unconscious memory) in protoplasm 
(Williams) ; hence every living thing produces new ones, each after its 
own kind. It is by virtue of this property that, in the words of Sir 
James Paget, " a mark once made in a particle of blood or tissue is 
not for years effaced from its successors." All are willing to admit 
that there is a difference in the susceptibility to disease among different 
individuals placed under the same conditions. Every military surgeon 
knows that if a body of troops is quartered in a cold, damp garrison, 
some will be attacked by catarrhal affections of different organs, others 
will suffer from rheumatism, while the greater number will retain their 
health after having been exposed to the same morbid influences. We 
must admit that a similar inherent susceptibility to tumor-formation 
exists among different persons, and that such individual predisposition is 
often the result of hereditary influences. Benign tumors are hereditary 
in the same sense as monstrosities — per cxccssiun. Supernumerary toes 



ETIOLOGY OF TUMORS. 63 

and fingers have appeared through several generations in the same 
family. The same can be said of most of the non-malignant tumors, 
particularly angioma and lipoma. Very frequently such tumors were 
not only hereditary, but also occupied the same localities. Paget found 
carcinoma of the uterus in three generations — grandmother, mother, 
and daughter. The writer has repeatedly met with carcinoma of the 
breast in two successive generations. Sibley relates an instance of 
carcinoma of the uterus affecting a mother and her five daughters. 
Warren observed a cancer of the lip in the father ; in one son and two 
daughters cancer of the breast ; and in two grandchildren cancer of the 
breast. The most interesting instance of hereditary predisposition to 
carcinoma is reported by Broca : 

First generation : Madame Z. died of cancer of the breast in 1788, aged 60. 
Second generation : four married daughters : 

A. Cancer of the liver, 62 years old, 1820. 

B. Cancer of the liver, 43 " " 1805. 

C. Cancer of the breast, 5 1 " " 1S14. 

D. Cancer of the breast, 54 '• " 1S27. 

Third generation : Madame B., five daughters and two sons : 

First son died during infancy. 

Second son, cancer of the stomach, 64 years old. 

First daughter, cancer of the breast, 35 " " 

Second " " " " -, 

Third '■' " " " 1 35-40 years old. 

Fourth " *• " liver, ) 

The fifth daughter escaped the disease. 
Madame C. had five daughters and two sons : 

The sons remained free from cancer. 

The first daughter died of cancer of the breast in 1837, 37 years old. 

Of her five children, one daughter died in 1S54, of cancer of the breast, at the age 
of 49. 

The second daughter died in 1822, 40 years old, of cancer of the breast. 

The third " " 1837, 47 " " " " uterus. 

The fourth " " 1848, 55 " " " " breast. 

The fifth " •• 1856,61 " " " " liver. 

From these and other reliable observations it is evident that a predis- 
position to cancer may be derived by inheritance. Paget collected the 
histories of 322 cancerous patients with special reference to this point. 
Of this number, there were seventy-eight, or nearly one-fourth, who 
were aware of cancer in other members of their families. The proportion 
is much larger than could be due to chance, and its import is corrob- 
orated by the fact of many members of the same family being in some 
instances affected. It is evident that where a tumor is inherited the two 
essential causes are transmitted from parent to child: 1. A matrix of 
embryonic cells ; 2. A lack of resistance on the part of the whole 



64 PATHOLOGY AND TREATMENT OF TUMORS. 

organism or of the tissues in the immediate vicinity of the matrix to 
retard tumor-growth. For the growth of a tumor it is not only essen- 
tial to have present the necessary matrix of embryonic cells, but it is 
equally essential that the environment of the matrix should not exert 
upon the cells an inhibitory influence which would interfere with their 
assuming active tissue-proliferation. If the controlling or inhibitory 
influence of the tissues in the vicinity of embryonic cells set apart in 
the organism is diminished or completely abolished, such cells regain 
their primitive reproductive activity and assume an individuality alone. 
Under such circumstances there is established a new centre of tissue- 
formation which has no laws to obey and no orders to observe. In 
such a new centre of growth there is a departure from the definite order, 
limitations, regular stages, and fixed periods of the normal growth. 
Little is known in regard to the force which holds in check perma- 
nently or for an indefinite period of time the tissue-proliferation from 
such a matrix. For want of a better knowledge this force has been 
called pliysiological resistance. Heredity implies, therefore, in connec- 
tion with the subject now under consideration, two things : i. A matrix 
of embryonic cells ; 2. Suspended or diminished physiological resist- 
ance in the tissues of the entire body or in the immediate vicinity of 
the tumor-matrix. The existence of such a force has been demon- 
strated by experiments. Cohnheim and Alaas introduced into the jugu- 
lar veins of animals small pieces of young periosteum, with the expec- 
tation that they would become arrested in the smaller branches of the 
pulmonary artery as emboli. The animals were killed in a few weeks 
or months later, and the specimens examined to determine the extent 
of tissue-growth from the periosteal grafts. The results were uniform. 
The periosteum retained its bone-producing properties and produced 
bone, but the new product was always limited in size to the lumen of 
the vessel in which the periosteal embolus had become impacted. 
When this size was reached further growth became arrested, and the 
new bone in the course of time underwent complete removal by 
absorption. It is apparent that the intrinsic force (physiological resist- 
ance) in the adjacent tissues exerted a positive influence in limiting the 
production of bone from the periosteal graft to the lumen of the vessel. 
The same investigators have also shown that transplantation of grafts 
of embryonal tissue is more successful than that of mature tissue. 
Leopold, under the direction of Cohnheim, studied the fate of mature 
tissue transplanted into the anterior chamber of the eye and the peri- 
toneal cavity in rabbits. He found that all tissue that had reached 
maturity was invariably removed by absorption in a short time, while 
embryonic tissue taken from animals before they were born retained its 



ETIOLOGY OF TUMORS. 65 

vitality and continued to proliferate tissue to an astonishing extent. 
Grafts of fetal cartilage increased to from two hundred to three hundred 
times their original size, giving rise to a temporary chondroma of several 
months' duration. Zahn repeated these experiments with the same 
results. In the growth of an osteoma tissue-proliferation takes place 
from a matrix of osteogenetic cells, and we must assume that in the 
immediate vicinity of the matrix a diminution of the physiological 
resistance of the tissues had taken place. In the transplantations of 
malignant tissue, that have almost without exception been followed 
by negative results, we can explain the failures only by taking it for 
granted that the tissues in which the graft was imbedded presented an 
adequate physiological resistance which prevented the growth and infil- 
tration of the transplanted cells, and that the graft acted the part of an 
absorbable foreign body, and was subsequently removed by the wall of 
granulations thrown out by the injured tissues around the graft. The 
physiological resistance in the adjacent tissues permits grafts from be- 
nign tumors only to grow to a limited extent if at all, after which they 
are removed like any other aseptic absorbable substance, while the same 
resistance offers an effective barrier to infiltration by cells from grafts 
taken from malignant tumors. From what has been said it follows 
that there are two essential factors present wherever a tumor grows — 
namely : /. An embryonal matrix, or at least a matrix composed of embry- 
onic cells ; 2. A suspension or diminution of the physiological resistance 
in the tissues in the immediate vicinity of the matrix. The absence of the 
former precludes entirely the possibility of the formation of a tumor, 
and only the presence of the latter negative condition enables the matrix 
to proliferate tumor-tissue. Future research must determine what con- 
ditions produce diminution of physiological resistance. We have reason 
to believe that this predisposition to tumor-formation is often hereditary, 
and that it can be produced artificially by acquired pathological con- 
ditions which weaken the tissues, such as irritation and inflammation. 
That the chemico-vital changes which take place in inflamed tissue 
diminish physiological resistance has been demonstrated unmistakably 
by the experiments of Friedlander. It is therefore reasonable to sup- 
pose that a person born with the essential tumor-germs is more likely 
to become the subject of tumor-formation when the part in which they 
are located becomes the seat of accidental pathological conditions which 
result in diminution of the physiological resistance in the, tissues sur- 
rounding the matrix ; while persons born with a similar matrix not thus 
affected may escape tumor-formation, the matrix-cells remaining in a 
latent condition throughout life. 

Race. — Race-influence plays an important part in the etiology of 



66 PATHOLOGY AND TREATMENT OF TUMORS. 

tumors. Certain races are predisposed to special tumors. Negroes 
suffer more frequently from the different forms of fibroma than does 
any other race. Keloid, fibroma of the skin, and myofibroma of the 
uterus in women are exceedingly common among the negroes in the 
South. Lipoma is very prevalent among the Hottentots. The unciv- 
ilized nations, in proportion to the population, furnish a smaller percentage 
of malignant tumors than do the inhabitants of Europe and America. 

Climate. — It is said that the inhabitants of southern countries are 
more predisposed to tumor-formation than are the inhabitants of the 
North; this applies particularly to carcinoma and sarcoma. Tumors 
of the thyroid gland appear as endemic affections in certain parts of 
Europe and in other countries. There is no doubt that malignant 
tumors are unequally distributed over the world, being more prevalent 
in some localities than in others. Heredity unquestionably plays an 
important part in imparting to these tumors in some localities an en- 
demic character. The accumulation of many generations in particular 
localities would naturally increase the number of the victims. 

Age. — Age has already been alluded to as an important determining 
cause. It is a familiar clinical fact that certain benign tumors from 
embryonic fetal remnants are likely to appear at the age of puberty, 
at the time of post-natal life when the whole organism, and particularly 
the organs of generation and the mammary gland in the female, are in 
a state of the highest physiological activity. It is during this time of 
life that we most frequently meet with branchial and dermoid cysts, cysts 
of the ovary and parovarian cysts, and adenoma of the mammary gland. 
In adult life fibroma, osteoma, chondroma, and other mesoblastic 
tumors are more prevalent. Carcinoma manifests a predilection for 
the conditions incident to senile marasmus, occurring most frequently 
in persons between fifty and seventy years of age. It is in individuals 
past middle life that we most frequently see transformation of benign 
growths, such as moles, papilloma, and warts, into malignant tumors. 
The conditions which determine such a change and which favor the 
formation of carcinomatous tumors are not well understood. There is 
anatomically such a thing as a non-malignant stage of cancer. In the 
early stage of epithelioma we find simply a superficial increase in the 
thickness of the epidermic layer — that is, the stage when carcinoma still 
remains as a non-malignant growth; but just as soon as the physio- 
logical boundary-line between the epithelial layer and the subjacent 
connective tissue is destroyed or is rendered permeable to migrating 
cells — in other words, just as soon as epithelial elements are found in 
places where they have no legitimate existence — we have to deal with 
a carcinoma. 



ETIOLOGY OF TV. MORS. 



Plate 2. 



,i 












& e 









" 













@ 



v 












. 








1. Endothelioma hyalinum from capsule of submaxillary gland (after Klebs) : a, stroma ; /■. smaller part of 
stroma ; c, hyaline substance ; d, cells. 2. Mucous membrane of large intestine of pig ; ■ 350 (nfter Klein). The 
capillary blood-vessels cut in different directions surrounding the crypts are injected with carmine gelatin. 3. A 
vertical section through the epithelium covering ihe skin epidetmis ; < 350 f after Klein) : «, rete Malpighii, or 
rete mucosum ; b, granular layer (Langerhans) ; c, stratum lucidum iSchron) ; d, stratum corneum. 



ETIOLOGY OF TUMORS. 



6 7 



A glance at Plate II., Figures 2 and 3, and at Figures 27 and 28 
Will show the difference in the relation of epithelial cells in normal tis- 






. 




/ 



- 



- 1 . 



Fig. 27. — Epithelioma of skin (after Thiersch) : 1-2, ulcerated surface; 2-3, adjacent skin; a, hair- 
follicles with sebaceous glands made oblique by pressure from beneath ; b, sweat-glands ; c, epidermis, horny 
layer, which extends for some distance over ulcerated surface ; d, avascular cell-masses of an epithelial 
nature, formed into irregular tubes by softening, only slightly attached to the stroma in which they are 
lodged, or separated from the walls of the alveoli during the hardening process in alcohol ; e, connective- 
tissue stroma. 




Fig. 2S.— Columnar epithelioma of rectum (after Boyce) : a, an epithelial process from skin of anus ; 6, a 
papillomatous gland-crypt. (Obj. { without eye-piece; logwood staining. ) 



sue and in carcinoma. In the former instance the epithelial cells are in 
an avascular district outside of the limiting membrane, membrana pro- 



68 PATHOLOGY AND TREATMENT OF TUMORS. 

pria ; in the latter instance they have found their zvay through the limit- 
ing membrane and liavc reached the underlying vascular mcsoblastic 
tissues, where they have no legitimate physiological existence, and where 
they must be regarded pathologically as invaders. It appears that in 
the subepithelial tissues a change takes place coincident with the senile 
changes in the tissues of persons advanced in life. Thiersch advanced 
the ingenious hypothesis that this change consists in a disturbance of 
the normal relations between the skin and the underlying tissues, this 
disturbance being caused by senile changes and resulting in a loss of 
resistance to the proliferating epithelial cells. There can be no doubt 
that in the aged some such alteration of tissue takes place, permitting 
embryonic epithelial cells to part with their normal anchorage and to 
find their way by migration into the subjacent altered tissue, where they 
arc no longer subject to the physiological laws which govern the repro- 
duction and growth of normal epithelial cells, and where, in consequence 
of such aberration and lawless conduct, they produce a planless, func- 
tionlcss growth "which invades all tissues, regardless of their anatomical 
structure. 

Sex. — Statistics show on the whole that the male sex is more 
predisposed to tumor-formation than is the female. This difference 
may be accounted for in part by the male sex leading a more active 
life, and being subjected more to the exciting causes which later in life 
become such a prominent feature in the etiology of tumors. Heredity 
affects both sexes equally, and the difference in the frequency with 
which tumors occur must therefore depend largely on occupation and 
habits of life. Of 1 145 cases of tumor treated at the clinic of Berne 
during a period of twenty-five years, the males furnished 58.5 1 per cent, 
and the females 41.49 per cent. C. O. Weber gives the proportion of 
males to females as 64 : 36. The proportion varies with the different 
forms of tumors. Carcinoma of the skin is much more frequent in the 
male than in the female, while in glandular carcinoma the reverse is 
the case. Moore in 1861 found in England one carcinoma patient 
to every 5846 men, and one female patient to every 2461 women. 
In women tumors are more prone to occur during the childbearing 
period of life than before and after. Carcinoma of the lip is common 
in men, but extremely rare in women. Of 696 cases of carcinoma of 
the lip collected by Lortet, 527 were men and 69 were women, the 
proportion of men to women being 7.6: 1. According to the writer's 
own observations, carcinoma of the stomach and the rectum is more 
frequently met with in males than in females. In the female, carcinoma 
of the breast and the uterus occurs probably more frequently than do 
malignant tumors of all the remaining organs. 



ETIOLOGY OF TUMORS. 69 

Social Status. — It has generally been claimed that the laboring 
classes furnish the largest contingent to the whole number of patients 
suffering from carcinoma. The statistics from which this statement was 
drawn were collected almost exclusively from the practice of hospital 
physicians. A more careful inquiry into the actual facts shows that 
the reverse comes nearer the truth. M. d'Epine found, in examining 
the mortality statistics of malignant tumors of the city of Geneva, that 
among the well-to-do classes came 106 deaths from this cause to every 
thousand inhabitants, while the poor furnished only 72 to every thou- 
sand. Walshe found that of a million of people in London in ten 
of the unhealthiest districts, 127 died of malignant tumors; in ten 
healthier districts, 183 ; and in ten of the healthiest, 199. From similar 
statistics gathered in England and Wales, Moore came to the conclu- 
sion that cancer becomes more frequent with the increasing prosperity 
of the people. 

Traumatism. — The influence of a trauma in exciting tumor-growth 
can no longer be denied. The different forms of sarcoma frequently 
follow an injury. Numerous cases are on record in which sarcoma 
followed a fracture of the long bones. The statistics of Boll, collected 
with a view to prove the traumatic origin of cancer, show that of a 
large number of cases only about 12 or 14 per cent, were traceable 
to traumatism. Traumatism alone can no more produce a tumor than 
can inflammation occur without the presence of pathogenic microbes. 
The trauma can act only as an exciting cause in stimulating a pre- 
existing matrix of embryonic tissue into active tissue-proliferation , or in 
furnishing by its remote effects on the tissue a post-natal matrix of 
embryonic cells. In animals sarcomata are seen most frequently in parts 
most exposed to injury — in fishes in the tail and fins, in frogs in the 
limbs, and in birds in the neck and wings. The writer believes that in 
a fracture of a bone which later becomes the seat of a sarcoma the 
cells which are destined to furnish the bony callus fail to undergo the 
typical transformation from embryonic into mature tissue in consequence 
of some local or general cause, and that from these cells the sarcoma 
takes its origin. Influenced by a preconceived idea, it is not difficult 
to trace many of the local affections, including tumors, to a traumatic 
origin. How long have we been in the habit of assigning to traumatism 
the first position in the causation of suppurative inflammation? Recent 
investigations have demonstrated that no amount of traumatism can 
produce inflammation and suppuration unless the injured tissues become 
infected with the essential cause of inflammation — pyogenic microbes. 
Trauma in exceptional cases may and does act as an exciting cause 
in the growth of a tumor, by diminishing the physiological resistance 



-JO PATHOLOGY AND TREATMENT OF TUMORS. 

of the injured tissues or by causing irritation or inflammation in the 
immediate vicinity of a pre-existing tumor-matrix ; or in more excep- 
tional cases it furnishes both essential conditions for tumor-growth — 
a post-natal matrix of embryonic cells and a diminution of physiological 
resistance in the immediate vicinity of the new matrix, 

Irritation. — Prolonged irritation — microbic, mechanical, chemical, 
and thermal — is a recognized exciting cause of tumor-growth. If we 
examine the topography of carcinoma, we find that it attacks parts 
and organs that are most frequently the seat of prolonged and repeated 
irritation. The clay pipe in smokers, the coal-dust in chimney-sweeps, 
foreign bodies in the tissues or in hollow organs, carious teeth, and 
other local irritants have for a long time been regarded as important 
causes in the production of tumors, more especially of carcinoma and 
sarcoma. The influence of alcoholic drinks in the production of car- 
cinoma of the oesophagus and stomach should be mentioned here. 
A similar chronic local irritation is the chronic catarrh of the mucous 
membrane of the nose which so often precedes the formation of 
myxomatous tumors in this locality. Virchow very correctly mentions 
the frequent occurrence of cancer of the testicle where the organ 
remains in the inguinal canal and is subjected repeatedly to pressure 
and traction. The ovary is equally liable to carcinoma if it constitutes 
a part of the contents of a hernia. We shall assign to irritation and 
inflammation an influence in the production of tumors similar to that 
assigned to traumatism. 

Inflammation. — Inflammation is never the sole cause of tumor- 
formation. That it is an important factor in stimulating pre-existing 
embryonic cells into a state of active tissue-proliferation few would 
deny. Friedlander has shown that embryonic epithelial cells, by virtue 
of their ameboid movement, can penetrate a subjacent inflamed sur- 
face. It has been shown that cancer-cells possess the same ameboid 
movement, which is a potent factor in the process of infiltration. 
Inflammation always hastens tumor-growth : this statement applies 
with particular force to malignant tumors. If a tumor-matrix is within 
the limits of an inflamed area, it receives suddenly an increased blood- 
supply, which alone may be sufficient to arouse it from its dormant 
condition into active tissue-proliferation ; at the same time the inflam- 
mation will result in diminution of the physiological resistance of the 
tissues around the matrix, thus still further favoring tumor-growth. 

Contagion. — Under this heading of the etiology of tumors it is only 
necessary to mention the malignant varieties, carcinoma and sarcoma. 
The popular fear of the contagiousness of these growths lacks founda- 
tion. There is not a single well-authenticated case on record in which 



ETIOLOGY OF TUMORS. 71 

the disease teas transmitted from man to man or from animal to animal 
by contagion. The cases in which the disease was reproduced in the 
same individual at a point opposite the primary tumor (by contact) or 
by bringing an ulcerating carcinoma frequently in contact with a distant 
part, as by rubbing (Kaufmann), are few, and the auto-inoculation was 
undoubtedly preceded by pathological conditions which in themselves 
might have furnished the essential conditions for tumor-growth, or 
which, at any rate, created a favorable soil for the implantation of tumor- 
cells. The negative results which have followed thousands of attempts 
to reproduce carcinoma and sarcoma by implantation of fragments 
of tumor-tissue in different animals furnish the most convincing proof 
of the non-contagious and non-parasitic character of malignant tumors. 



VII. CLINICAL ASPECTS OF BENIGN AND 
MALIGNANT TUMORS. 

The clinical behavior of a tumor is determined by the nature of the 
primitive matrix, the anatomical structure and physiological importance 
of the part or organ affected, and the relations of the tumor to the adja- 
cent tissues. A tumor-matrix composed of embryonic cells of the 
lowest degree of development is more likely to result in the formation 
of a malignant tumor than is a matrix representing embryonic cells 
capable of development into tissue of the highest physiological type. 
Again, the type of a tumor will depend upon the germinal layer from 
which the matrix is derived. A matrix from the middle germinal layer 
will produce a tumor of the connective-tissue type — either a benign meso- 
blastic tumor or a sarcoma. A matrix of embryonic cells from the cpiblast 
or hypoblast will give rise to cither a benign epithelial tumor or a carci- 
noma according to the intrinsic capacity of the cells to produce embryonic 
or mature cells, and the resisting power of adjacent tissues. A tumor 
of an important organ, such as the brain, heart, lungs, or digestive 
tract, may destroy life by its presence producing mechanical conditions 
incompatible with an essential function. Large tumors of less import- 
ant organs may by compression of an important organ produce the 
same result. Malignant tumors affecting important organs not only 
give rise to functional disturbances by their mere presence, but they 
also destroy the tissues of the part or organ affected, thus greatly 
increasing the danger to life. A benign tumor remains limited to the 
part or organ primarily affected ; malignant tumors, on the contrary, 
ignore all boundary-lines and affect adjacent tissues irrespective of their 
anatomical structure. 

Relative Frequency with which Different Organs are Affected 
by Tumors. — Every clinician knows that certain tumors show a predi- 
lection for certain tissues and organs. Fatty tumors occur most fre- 
quently in the panniculus adiposus, enchondroma in the long bones ; 
sarcoma affects most frequently the connective tissue, the glands, and 
the bones, while the muco-cutaneous orifices and the mammary gland 
are the most frequent seat of carcinoma. C. O. Weber arranged the 
following table of organs and parts to show their predilection for 
tumor-formation : 



BENIGN AND MALIGNANT TUMORS. 

No. of Cases. 

Organs of mouth, with maxillary bones 217 

Glands I j, 

Bones, excluding maxillary bones Itn 

Skin 93 

Genital glands 85 

Lun gs 64 

Nose, pharynx, antrum of Ilighmore r6 

Subcutaneous and intermuscular connective tissue, muscles, and nerves . . 51 

Eyes and orbits , T 

Genitals, including uterus ?i 

Intestines and anus n 

Urinary organs t 7 

Brain I -» 



73 



That the relative frequency with which different tissues and organs 
are affected is inaccurately represented by this table follows from the 
fact that it undoubtedly includes many chronic infective swellings which 
were formerly classified with tumors, and which even now are often 
mistaken for tumors ; but the table is valuable in giving at least an 
approximately correct idea of the topographical distribution of tumors. 

Benign Tumors. — A benign tumor always grows slowly. Myofi- 
broma of the uterus under favorable circumstances may attain great size 
in the course of a few years (Fig. 29). Fibromata in other localities grow 
less rapidly. Among the tumors of slow 
growth, which, however, eventually often at- 
tain great size, are the cystic adenomata and 
chondromata. Slowness of growth must there- 
fore be looked upon as an important clinical 
feature of a benign tumor. Every benign 
growth is surrounded by a limiting capsule, 
which separates it from the adjacent tissues, 
and beyond which it never extends. Tins isola- 
tion from the surrounding tissues is the most 
distinctive anatomical feature of benign as 
compared with malignant tumors. The exist- 
ence of this connective-tissue capsule enables 
the surgeon in the majority of cases to remove benign tumors by enu- 
cleation. If the capsule of a benign tumor, owing to anatomical pecu- 
liarities of the surroundings, sends prolongations into the adjacent 
tissues, as is sometimes the case in lipoma and fibroma, parts of the 
tumor may be overlooked by the surgeon, and from them takes place 
a local recurrence later. We are therefore prepared to appreciate the 
force of the statement that incomplete removal of a benign tumor is 
always followed by recurrence unless the remaining part of the tumor 




Fig. 29. — Submucous pedunculated 
myofibroma of the uterus (after 
Paget): a, capsule; b, tumor. 



74 PATHOLOGY AND TREATMENT OF TUMORS. 

is subsequently destroyed by suppurative inflammation or by degenerative 
changes. 

Encapsulation of a tumor imparts to it another clinical feature of 
great importance — mobility. This mobility, however, may be diminished 
or entirely prevented by the tumor being tied down by overlying firm 
structures, such as fascia, skin, and muscles. If the tumor is attached 
to the bone, as is the case in chondroma and osteoma, it is from the 
beginning immovable, and so remains. The question of mobility of 
a tumor is a valuable point in differential diagnosis, and is of special 
importance in the case of tumors of the breast. An adenoma of the 
mammary gland always remains movable, while in carcinoma of this 
organ the tumor almost from the beginning is so intimately connected 
with the surrounding tissues that the palpating finger receives an im- 
pression as though the tumor were grasped and firmly held in place 
by the surrounding tissues. Some of the benign tumors — myxoma, 
chondroma, and some forms of fibroma — have received the reputation 
of being semi-malignant on account of their occasional recurrence after 
extirpation. A tumor is cither benign or malignant : there is no connect- 
ing-link betiucen them. The recurrence of a tumor after extirpation may 
be explained as follows: i. The tumor was incompletely removed; 

2. The primary tumor removed was malignant from the beginning; 

3. A new tumor may develop in the scar of the operation-wound or 
in its immediate vicinity. Local recurrence after the removal of a 
benign tumor has been observed most frequently in cases of chon- 
droma, myxoma, and fibroma — tumors which, from their clinical 
behavior as well as from the fact that their extirpation is sometimes 
followed by recurrence, have been regarded by many surgeons as 
suspicious or semi-malignant growths. We have reason to believe that 
in most cases local recurrence was due to imperfect removal. These 
tumors have a structure which renders their complete removal uncer- 
tain. Fibroma, for instance, is often surrounded by minute nodules, not 
large enough to be recognized by the naked eye, which are in histo- 
genetic connection with the main tumor, and which, if the main tumor 
is removed by enucleation, remain in the tissues ; from these nodules 
a recurrence takes place later. Such minute daughter-tumors are no 
evidence of the malignant nature of the primary tumor, as their histo- 
genetic connection with the primary tumor can be demonstrated. The 
jelly-like structure of a myxoma renders the outline of the tumor 
irregular. Projections of the tumor between muscles and connective 
tissue are often overlooked, and if left in the bed of the tumor they 
certainly would give rise to local recurrence. Virchow years ago 
showed that chondroma originates not from the surface of a bone, but 



BENIGN AND MALIGNANT TUMORS. Plate 3. 









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Glandular carcinoma of the breast (after Klebs) : a, epithelial layer of skin with long proliferating projec- 
tions ; b, carcinoma-ti.ssne of epithelial cells and connective tissue ■ c, the same with predominance q[ epithelial 
cells ; d, milk-ducts. 



BENIGN AND MALIGNANT TUMORS. 75 

in its interior. Surgeons seldom extend the operation far enough to 
include every vestige of the tumor, hence the frequency with which 
an enchondroma returns. If a tumor is removed completely and local 
recurrence takes place, it is more than probable that the primary tumor 
was of a malignant character, and that the relapse is the result of tissue- 
proliferation from malignant cells left in the tissues. The clinical course 
of the tumor in such cases makes a more positive and reliable diagnosis 
than the surgeon and pathologist. Finally, a nezv tumor may grow from 
an additional congenital matrix of embryonic cells or from latent unutilized 
embryonic cells in the scar or in its immediate vicinity. 

Malignant Tumors. — To the surgeon the most important clinical 
aspects of a malignant tumor are — 1. Rapid growth; 2. Absence of 
limitation of the growth ; 3. Local infection ; 4. Regional infection ; 
5. General infection; 6. Frequency of recurrence after extirpation; 
7. The intrinsic tendency of the tumor to destroy life. Rapidity of 
growth, as compared with that of benign tumors, belongs to malignant 
tumors as one of their salient clinical features. Some malignant tumors, 
particularly epithelioma of the skin, may remain in a latent stage for 
years before manifesting their true nature by rapid growth ; these are, 
however, exceptional cases. 

Absence of a limiting capsule is common to all malignant tumors. 
In some forms of sarcoma, to the naked eye such a capsule exists, but 
examination of the tissues adjacent to it under the microscope shows 
that tumor-cells have passed through and beyond the capsule into the 
connective tissue. The apparent capsule in such cases has been a 
source of deception to the surgeon who enucleates such a tumor under 
the belief that it is non-malignant. The absence of a proper limiting 
capsule brings the tumor-tissue in direct contact with the surrounding 
tissues, giving rise to local infection. The word " infection " as applied 
to the process of dissemination of malignant tumors has a different 
significance than when the same term is applied to the origin and 
extension of acute and chronic infective diseases. In the latter case 
infection signifies the presence in the tissues of pathogenic microbes 
which exert their specific pathogenic effect upon pre-existing tissues. 
The word infection used to indicate the local, regional, and general dis- 
semination of malignant tumors means the separation from the primary 
tumor of cells which migrate into the surrounding connective tissue, giving 
rise to local infection, or which arc transported through the lymphatics of 
the region occupied by the tumor, causing regional infection ; or, lastly, 
the malignant cells find their way directly or indirectly into the general 
circulation and become arrested in some distant part or organ as tumor- 
emboli, resulting in general infection or general dissemination. 



76 PATHOLOGY AND TREATMENT OF TUMORS. 

Local Infection. — Local infection of a malignant tumor is caused 
by the migration of tumor-cells from the place in which they were 
produced — that is, from the primary tumor — into the connective-tissue 
spaces in the immediate vicinity of the tumor. This migration of cells 
in all directions around the tumor results in a zone of tissue-infiltration 
by malignant cells, each cell establishing in its new location an inde- 
pendent centre of tumor-growth. As soon as a malignant cell lias left 
its birthplace, it leads an independent existence and loses all Mitogenetic 
connections with the mother-tumor. It is the establishment of innumerable 
independent centres of tissue-proliferation in the soue of infiltration sur- 
rounding a malignant tumor that determines its rapid growth. Infec- 
tion from a malignant tumor implies, therefore, only the invasion of 
adjacent or distant tissues by malignant cells ; it is an infection by cells 
instead of by microbes, as is the case in the production of infective diseases. 
Another great. difference in the two kinds of infection is this: in infec- 
tive diseases the microbes act upon and alter pre-existing tissue-cells, 
while in tumor-growth the pre-existing tissue remains passive, the tis- 
sues of the tumor being derived exclusively from the tumor-cells. 
As a rule, local infection is much more pronounced and rapid in sar- 
coma than in carcinoma, hence greater rapidity of growth and larger 
size of the tumor. 

Regional Infection. — Regional infection consists in the transporta- 
tion of tumor-cells through the lymphatic channels some distance from 
the tumor to the lymphatic glands in the region occupied by the tumor. 
Familiar instances of regional infection are secondary carcinoma of the 
submental, submaxillary, and cervical glands in advanced carcinoma of 
the lip, and secondary carcinoma of the axillary glands in glandular 
carcinoma of the mammary gland. The regional dissemination of car- 
cinoma is accomplished almost exclusively through the medium of the 
lymphatics. The carcinoma-cells, after finding their way into a lym- 
phatic channel within or near the tumor, are transported by the lymph- 
current, and are arrested usually in the first lymphatic gland, which 
acts the part of a filter. The cell or cells establish here a new centre 
of growth, from which the tissues of the ensuing secondary carcinoma 
of the lymphatic gland are derived exclusively, the lymphoid cells 
taking no active part in the production of the tumor. From a gland 
thus infected tumor-cells again reach the lymphatic channel on the 
opposite side of the gland, and are taken up by the lymph-current and 
transported to the next lymphatic gland, where an additional centre of 
tumor-growth is established. By this progressive regional extension 
of the tumor the whole chain of glands between the primary tumor 
and the proximal termination of the lymphatic system becomes in- 



BENIGN AND MALIGNANT TUMORS. 



11 



volved. The lymphatic glands serve as filters and contribute much 
toward retarding general dissemination. General infection is likely to 
occur at an early date if the lymphatic glands do not participate in the 
regional extension of the tumor. The malignant cell after it has 
become detached from the mother-tumor retains all the qualities in- 
herited from it at birth, and consequently produces the same kind of 
tissue, whether it remain in the vicinity of the tumor in the same region 
or whether it is transported to the most distant organs. The secondary 
tumors resemble the primary tumor histologically and clinically (Fig. 30). 
Regional dissemination of a sarcoma takes place by a continuous 
growth of the tumor, usually in the direction of fascia, blood-vessels, 
or nerve-sheaths : it is a local infection on a large scale. Occasionally 
a sarcoma gives rise to regional 
infection in the same manner 
and through the same channel 
as carcinoma. 

Another method of regional 
infection takes place by the dif- 
fusion of particles of tumor- 
tissue or free tumor-cells over 
serous surfaces — in the abdom- 
inal cavity by the peristaltic 
movements of the intestines and 
the stomach, and in the pleural 
cavity by the movements of the 
lung during respiration. This 
manner of regional infection is witnessed most frequently in sarcoma 
of the peritoneum and the pleura, and in carcinoma of any of the 
abdominal organs or of the lung after the tumor has reached the serous 
cavity. 

General Infection. — General infection during the growth of a malig- 
nant tumor is called metastasis — that is, the reappearance of the same 




Fig. 30. — Secondary sarcoma of lymphatic vessels of omen- 
tum in the course of a medullary sarcoma (after Liicke). 



disease in a distant organ. 



When this stage is initiated the tumor is no 



longer local : the disease has become general. No modern pathologist 
regards — as was formerly and quite recently done — a primary malig- 
nant tumor as a local manifestation of a general disease or dyscrasia. 
A careful study of the pathology and histology of malignant tumors, 
as well as the results of accurate clinical observation, has demon- 
strated that malignant tumors are primarily purely local affections, 
amenable to successful surgical treatment, and that they become gen- 
eral only by the dissemination of tumor-cells through the systemic 
circulation. Metastasis may occur in one of three ways: 1. Tumor- 



78 PATHOLOGY AND TREATMENT OF TUMORS. 

cells reach the venous circulation directly by their entrance from the 
primary tumor or the regional glandular tumors into a vein ; 2. By 
progressive extension of the disease through the lymphatic channels 
until the last filter, the last lymphatic gland, is passed, when the 
tumor-cells reach the general circulation ; 3. By the passage of tumor- 
cells through the chain of lymphatic glands into the pulmonary or 
systemic circulation without implicating the lymphatic glands. It is 
strange that the tumor-emboli are not more constantly arrested in the 
finer branches of the pulmonary artery. The result of post-mortem 
examinations of persons who died of malignant tumors would tend to 
show that such emboli readily pass the pulmonary filter, and may 
become arrested in any of the more distant vascular organs. The 
exemption of non-vascular tissues from metastatic carcinoma is one of the 
many proofs that malignant tumors arc generalized by cellular elements, 
and not through the agency of a virus or of microbes. Metastasis always 
takes place through the arteries. Usually the emboli are small (Fig. 31). 
In some cases perhaps a single cell becomes implanted upon the wall 
of an arteriole, and later a thrombus is formed by tissue-proliferation 
from this cell. In other instances a vessel of considerable size is 
obstructed by a malignant thrombus. Metastatic tumors frequently 




Fig. 31. — Embolism of the right pulmonary artery from a pigmented sarcoma of the thigh (after Liicke). 

extend in the direction of a blood-vessel of considerable size, the mul- 
tiple tumors with the blood-vessels and its branches presenting the 
appearance of a bunch of grapes (Fig. 32). 



BENIGN AND MALIGNANT TUMORS. 



79 



The number of emboli varies greatly, from a single metastatic tumor 
to thousands of nodules. In some very malignant forms of carcinoma 
and sarcoma the nodules are so numerous that the appearance of the 




Fig. 32. — Medullary nodules in the course of an artery of the great omentum following a primary carcinoma 

of the right tonsil (after Liicke). 



internal organs resembles very closely that of miliary tuberculosis. 
Metastasis occasionally takes place in the aged who have been the sub- 
jects of latent carcinoma for years. In some instances the patients 
were not aware of the existence of the primary tumor until the pres- 
ence of a large and destructive metastatic tumor gave occasion to 
consult a physician. Sarcoma gives rise to general infection more 
constantly and at an earlier date than does carcinoma. Small-celled 
sarcoma is more frequently followed by early and diffuse general dis- 
semination than are large-celled tumors. 

Frequency of Recurrence after Extirpation. — It has been shown 
that the recurrence of a benign tumor is always local, and is invariably 
the result of incomplete removal of the tumor. The recurrence after 
the removal of a malignant tumor is either local or metastatic — in the 
former instance caused by incomplete removal of the primary tumor, 
and in the latter instance a sad reminder that the operation was not 
performed early enough to protect the patient against general infection. 



8o PATHOLOGY AND TREATMENT OF TUMORS. 

The most competent surgeons are willing to admit that so far the best 
results of operations for malignant disease have not yielded more than 
about 15 to 25 per cent, of permanent recoveries. If we recollect how 
a malignant tumor reaches out in all directions into tissue which to the 
naked eye presents every indication of being normal, we can readily 
understand why local relapse should follow so frequently even after 
what seemed a thorough operation. Again, every surgeon has reason 
to regret that in most cases he is called upon to operate for malignant 
tumors after the disease has advanced beyond the limits of a successful 
radical operation. In some instances no local recurrence takes place, 
but the operation was performed too late, and the patient succumbs 
sooner or later to metastatic carcinoma or sarcoma. In such cases 
general infection had taken place when the operation was performed. 
A local recurrence may take place from three to seven years after the 
operation for carcinoma of the breast, as happened in a number of the 
writer's cases, and it may be postponed, according to Billroth, twenty 
years from the time of operation in cases of sarcoma. Sarcoma usually 
returns in the scar; carcinoma, either in the scar or in the adjoining 
lymphatic glands. 

Intrinsic Tendency of the Tumor to Destroy Life. — If we reflect 
upon the fact that with the best efforts of the surgeon only 15, and at 
best only 25, per cent, of all persons suffering from malignant tumors 
escape a painful and lingering death from their immediate and remote 
effects, we must admit that the intrinsic tendency of a malignant tumor 
is to destroy life. The average duration of life of all persons suffering 
from malignant tumors of all kinds and of all parts and organs of the 
body, without surgical intervention, is about three years. It is a source 
of satisfaction to the surgeon to know that life is prolonged by radical 
attempts to remove malignant tumors, and that in a fair proportion of 
cases the disease never returns. Life is destroyed by regional or gen- 
eral dissemination involving important organs, by the primary tumor 
interfering with the function of an important organ, by hemorrhage, or, 
lastly, by a progressive chronic sepsis or septico-pyasmia caused by 
an open ulcerating carcinoma or sarcoma. The so-called " cachexia " 
which appears so constantly some time before the fatal termination 
is the result of impaired nutrition and of the introduction into the cir- 
culation from the tumor of toxic substances. 



VIII. TRANSFORMATION OF BENIGN TUMORS 
AND POST-NATAL EMBRYONIC TISSUE INTO 
MALIGNANT TUMORS. 

The possibility of the transformation of a benign into a malignant 
tumor has been asserted by a few and denied by most of the older 
writers on surgical pathology. The subject is of great interest to the 
pathologist, and of equal practical importance to the surgeon. Accum- 
ulated clinical observations, since the diagnosis of tumors has been 
made more accurate by increased knowledge of their pathology and by 
a more frequent resort to the use of the microscope in the examination 
of tissue removed for diagnostic purposes and of fresh specimens after 
operation, have brought more convincing proof of the possibility of 
such an occurrence. As the result of his own observations the writer 
is convinced not only that such a transformation is possible, but also 
that it takes place much more frequently than has heretofore been 
supposed. The writer is equally certain that malignant tumors not 
infrequently originate from embryonic tissue of post-natal origin. 

Transformation of Benign into Malignant Tumors. — The trans- 
formation of a benign into a malignant tumor implies a change in the 
histological structure of the cells of the benign tumor as well as a cliange 
in its environments. \Ye have seen that the cells of which benign 
tumors are composed resemble the normal cells of the part or organ 
in which the tumor is located. In a myofibroma of the uterus the cells 
resemble the connective tissue and the unstriped muscle-cells in the 
uterine wall in which the tumor is located. The epithelial cells in an 
adenoma of the breast cannot be distinguished from the epithelium of 
the acini and tubules of the mammary gland. The transformation 
depends, therefore, upon influences which accomplish such a change 
from mature into embryonic cells. At the same time, and probably 
from the same causes, the physiological resistance of the adjoining 
tissues is diminished. 

The liability of benign tumors to become malignant is of interest 
not only as a subject of pathological study, but also in relation to an 
opinion which is often made an argument for operations — namely, that 
if a tumor of any kind is left to pursue its own course, it is not unlikely 
to become malignant. This belief, which is entertained by the general 

6 81 



82 PATHOLOGY AND TREATMENT OF TUMORS. 

mass of the people, is a strong inducement for patients suffering from 
benign tumors to submit themselves to a timely operation. This pop- 
ular belief should be strengthened, not undermined, by the medical 
profession, as by doing so the patient's mind is relieved and all liability 
to malignant disease from malignant tumors is removed, and this in- 
formation and consolation should be imparted to the patient. Lebert 
states that he has twice met with tumors which were first benign, but 
afterward became cancerous. 

Pirogoff relates three cases in' which the removal of angioma was 
followed by sarcoma at or near the seat of operation. 

Benjamin Brodie relates a case in which he removed a tumor the 
general mass of which appeared to be fatty substance somewhat more 
condensed than usual, but " here and there was another kind of morbid 
growth, apparently belonging to the class of medullary or fungoid 
disease." 

Lebert and Benjamin Brodie reported each a case of unquestionable 
transformation of a benign into a malignant tumor. A few other 
isolated cases are recorded, but such serious doubt was entertained 
concerning this matter that at the time Sir James Paget published his 
Lectures on Surgical Pathology (1870) he expressed himself in a veiy 
guarded way on this subject : " It need not be denied that cancerous 
growths may occur in tumors that were previously of an innocent kind, 
but I feel quite sure that these may be regarded as events of the 
greatest rarity." He believes that such transitional tumors were malig- 
nant from the very beginning, and that the benignant stage simply 
indicated latency of a carcinomatous growth. The occurrence of a 
carcinoma in a scar following an operation for the removal of a benign 
growth he attributes to the trauma acting on the tissues and furnishing 
the necessary stimulus to the development of a carcinoma in persons 
so predisposed by heredity. 

Since Paget wrote on this subject numerous cases have been recorded 
in which at the operation such mixed tumors were found, and in which 
cases there could have been no doubt of the benign nature of the 
primary tumor. An interesting case of this kind came under the 
writer's observation. The patient was a married woman fifty-two years 
of age, the mother of several children. For at least ten years she 
suffered from a pelvic difficulty which six years ago was diagnosed as 
myofibroma of the uterus. Since that time she has suffered from pro- 
fuse menstruation. Examination disclosed a smooth tumor occupying 
the middle of the lower part of the abdominal cavity and reaching as 
far as the umbilicus. On vaginal examination the lower segment of 
the uterus was found high up and was affected by the movements of 



TRANSFORMATION OF TUMORS. 



\ 






k-'-i- /£ 



-: 



83 




Fig. 33. — Myofibroma uteri ; X 150. 







|v 

m * t 



-_, 



c 
Fig. 34. — Sarcoma which started in a myofibroma uteri : transformation of a myofibroma into sarcoma ; X 485. 



84 PATHOLOGY AND TREATMENT OF TUMORS. 

the tumor. The absence of metrorrhagia and the clinical history spoke 
in favor of the diagnosis previously made. On opening the abdomen 
there was found what appeared to be a large myofibroma of the uterus 
springing from the fundus between the cornua. The immobility of the 
pelvic part of the tumor induced the writer to make a more thorough 
examination, which revealed extension of the tumor-mass from the uterus 
to the broad ligament on the right side. The operation proved to be a 
very difficult one. The entire uterus, with the pelvic mass on the right 
side, was removed. An examination of the specimen showed an intersti- 
tial myofibroma, the lower segment soft and continuous with the extra- 
uterine part of the tumor. Microscopic examination of the upper, dense 
part of the tumor showed the characteristic structure of a myofibroma 
(Fig. 33), while sections from the lower part of the tumor, the infil- 
trated uterine wall, and the extra-uterine part of the tumor presented 
the typical picture of round-celled and spindle-celled sarcoma (Fig. 34). 
There could be no doubt in this case that the myofibroma had existed 
for at least ten years, and, as the sarcoma constituted a part of the 
tumor, it was evident that it occupied that part of the tumor which had 
undergone transformation from a benign into a malignant tumor. The 
sarcomatous degeneration did not remain limited to the tumor in which 
it had its origin, but extended to the uterus, and from here to the tis- 
sues outside of it, but in connection with it. The writer has seen in the 
aged a number of instances in which papilloma assumed active growth 
after having been in existence for twenty or more years, and manifest 
clinical evidences of their transition from benign into malignant tumors ; 
he has also witnessed the development of the most malignant form of 
sarcoma in a small fibroma of the skin that had existed as a benign 
tumor for years. The origin of sarcoma from pigmented moles is of 
common occurrence and is generally recognized. In other cases the 
na;vus pigmentosus is transformed into carcinoma. If the mole under- 
goes this transition, the principal seat of the carcinoma is in the super- 
ficial layer of the cutis and the rete mucosum, the altered cell-prolifera- 
tion being limited to the epiblastic structures of the mole. 

The exciting causes in effecting a transition of a benign into a malig- 
nant tumor are such local and general influences as transform mature 
cells into embryonic cells, and which at the same time render the sur- 
rounding tissues more passive to cell-infiltration. Among the local 
causes may be enumerated injury, prolonged or repeated irritation, and 
incomplete removal of the benign tumor by excision or by cauterization. 
The writer regards the incomplete removal of a benign growth by the 
application of caustics as one of the most fruitful sources in the trans- 
formation of a benign into a malignant tumor. Papilloma and fibroma 



TRANSFORMATION OF TUMORS. 85 

of the skin in localities exposed to friction by the clothing, the sus- 
penders, etc. are liable to undergo such a transition. The incomplete 
removal of a myxoma of the nasal cavities by ecraseur, forceps, or paren- 
chymatous injections, if these procedures are frequently repeated, is veiy 
liable to give rise to sarcomatous degeneration of the growth. The 
senile state appears to exert a general influence which favors the change 
of an innocent into a malignant tumor. Malignant tumors starting from 
a benign tumor are met with most frequently in persons advanced in 
years who were the subjects of benign tumors for from ten to thirty 
years, and the clinical history usually points to agencies enumerated 
above which have brought about this transition. 

Transformation of Embryonic Tissue of Post-natal Origin into 
Malignant Tumors. — Cohnheim's theory of the origin of tumors is 
not applicable to tumors originating in the products of a chronic in- 
flammation or in scar-tissue. The writer has for years maintained 
that embryonic tissue of post-natal origin may in the production of 
tumors serve the same purpose as Cohnheim's congenital matrix. 
It is not difficult to understand that embryonic cells, during the pro- 
cess of regeneration after inflammation or in the healing of a wound 
or a fracture, may fail to undergo evolution into so complete a state 
of perfection as the maternal cells which produced them, and that 
such cells are set aside, and remain in the tissues in a latent condition 
in a manner similar to that claimed by Cohnheim for his congenital 
matrix of embryonic cells. The exciting causes which stimulate such 
a matrix to tissue-proliferation are of the same nature as those de- 
scribed in the section on the Etiology of Tumors. The kind of tumor 
produced by such a matrix will correspond to the type of tissue from 
which the matrix was derived. Epithelial cells buried in a scar will 
produce an epithelioma. In the healing of a burn some of the new 
epithelial cells which are derived from the epiblast and which are not 
utilized in the process of epidermization become buried in the scar- 
tissue, remain in an immature state, and not infrequently become later 
the starting-point of an epithelioma. Every surgeon knows that car- 
cinoma not infrequently develops in scar-tissue. Such an origin of 
carcinoma is not limited to the surface of the body. Gynecologists 
have claimed for many years that carcinoma of the cervix of the uterus 
is very prone to develop in the scar-tissue produced by extensive 
laceration of the cervix during labor. The embryonic cells upon which 
depends callus-production, when for some reason, local or general, they 
fail to develop into mature tissue, not infrequently constitute the matrix 
of tumor-formation, and instead of a normal callus a sarcoma is pro- 
duced. Not long ago the writer observed an interesting case of this 



86 PATHOLOGY AND TREATMENT OF TUMORS. 

kind : A man fifty years of age, apparently in perfect health, riding 
on horseback through a woods, struck his right shoulder against a 
tree. He was unable to use his arm after the injury. The physician 
who examined the case pronounced the injury a fracture of the surgical 
neck of the humerus. The fracture was treated in the customary man- 
ner. Three months later, another physician gave it as his opinion that 
the original injury consisted of a dislocation of the shoulder-joint for- 
ward and fracture of the upper part of the humerus. Six months 
after the injury the patient entered St. Joseph's Hospital, Chicago. 
The patient was unable to use the arm. The upper part of the 
humerus was surrounded by a swelling which in the subcoracoid 
region presented on palpation distinct fluctuation. About the centre 
of the swelling an additional point of motion indicated that the fracture 
had not united. Exploratory puncture of the tumor at a point corre- 
sponding to the fluctuating area yielded blood and a few minute frag- 
ments of tissue resembling in their naked-eye appearances granulation- 
tissue. The patient complained of a great deal of pain in the tumor, 
extending in the direction of the shaft of the humerus. As the pain 
was greatly aggravated during the night, the patient was placed on 
gram doses of potassic iodide with mercurial inunctions over the 
swelling. This treatment was continued for nearly two months with- 
out making any impression on the subjective symptoms or on the size 
of the tumor. Amputation through the shoulder-joint was made. The 
upper five inches of the humerus was found almost completely de- 
stroyed by a central myeloid sarcoma which had evidently started at 
the seat of the fracture. The cartilage of the humerus was completely 
detached by the tumor-mass, and the disease had reached the capsule 
of the joint, which was carefully dissected away. The patient does not 
recollect having suffered any pain or impairment of function of the arm 
prior to the injury; hence it is safe to assume that the sarcoma devel- 
oped, in consequence of the injury, from the embryonic tissue, which 
was arrested in its development into mature tissue by unknown local 
or general influences. 

Maas illustrates the influence of traumatism in effecting transition 
from a benign into a malignant tumor by reporting the case of a med- 
ical student who had at the inner termination of the eyebrow an ordinary 
small congenital angioma which was injured by a sabre-cut in a duel. 
Within two years a racemose aneurysm developed in the scar. Maas 
concludes that trauma can result in the formation of a tumor if the 
essential embryonal matrix is present at the site of injury. We have 
seen that a trauma acts as an exciting cause in provoking active tissue- 
proliferation from a latent matrix of congenital embryonic cells, but 



TRANSFORMATION OF TUMORS. 87 

the case of Maas just quoted admits of another and more satisfactory 
explanation. In the repair of the vessel-wounds inflicted by the sabre- 
cut the angioblasts must necessarily have taken an active part. In the 
event of the new cells failing to undergo the necessary developmental 
stages requisite in the ideal healing of an injured part, they would, 
according to our position, become available as tumor-forming elements, 
and their histogenetic origin would determine the production of a vas- 
cular tumor of more active tendencies than the primary tumor. The 
writer therefore believes that the trauma, instead of acting only as an 
exciting cause, in this case furnished also the necessaiy tumor-matrix. 
The relationship of irritation to tumor-formation has recently increased 
in prominence. As is well known, the psoriasis lingualis, laryngis, na- 
salis, and prseputialis, and the seborrhcea senilis of Richard Volkmann, 
have engaged, and still engage, very considerable attention. Schuchardt 
in 1885, Rudolph Volkmann in 1889, and others have brought together 
a very considerable number of surface tumors which were preceded by 
long-standing sources of irritation and inflammation, such as, for ex- 
ample, those originating from soot-sifting, tar- and paraffin-working, 
chronic sinuses, and lupoid and syphilitic ulceration. Cases in which 
there existed a combination between syphilis and carcinoma have been 
reported by Lang and Doutrelepont. In 1859, O. Weber showed the 
etiological relations of lupus to carcinoma, and cases substantiating the 
correctness of his observations were reported later by Von Esmarch, 
Hebra, Lang, and others. Neisser reminds us that " one ought not to 
forget that complications of carcinoma and lupus occur, and in these 
cases, owing to lack of resistance, in part, of the lupus tissue against the 
encroaching cancer papilla?, it is advisable to adopt early therapeutic 
measures." Lesser commits himself on this subject as follows: "Occa- 
sionally pathological changes in tissue are the seat of epithelial carcino- 
mata which are in no way directly responsible for the origin of tumors, 
such as ulcers of the leg, syphilitic ulcerations, lupus, etc." E. Friend 
of Chicago, under the tutorship of Kaposi made a very careful study 
of the microscopic picture of tissue representing a combination of lupus 
and carcinoma. Friend saw three cases of lupus vulgaris of the face 
complicated by carcinoma in Kaposi's clinic (Fig. 35). The probabilities 
arc that the atypical proliferation of the epithelial cells in the inflamed 
tissues, and the diminished physiological resistance of the tissues in their 
immediate vicinity, arc the important factors in the production of carci- 
noma in lupoid tissue as well as in other pathological conditions represent- 
ing embryonic epithelial cells with a similar environment. The writer has 
seen a number of instances in which a carcinoma developed on the sur- 
face of a chronic ulcer of the leg. In such cases the islets of embryonic 



88 PATHOLOGY AND TREATMENT OF TUMORS. 

epithelial cells become the starting-point of a carcinoma when the causes 
which maintain the ulceration have succeeded in diminishing the physio- 
logical resistance of the tissues in their vicinity sufficiently to permit the 




Fig. 35. — Carcinoma in lupoid tissue (after Friend). Isolated tissue-masses, called by Leloir " lupoma," 
lie irregularly and at different depths in the corium. Upper and papillary layer and rete Malpighii appear 
normal. Below and interspersed in these nodules are round and elliptical bodies with nests of epithelial cells. 
Section from lupus vulgaris of face complicated by carcinoma. (Zeiss, A., ocular No. 3.) 

embryonic epithelial cells to migrate into the surrounding tissues. We 
must therefore admit that the transformation of a benign growth and of 
a matrix of embryonic cells of post-natal origin into a malignant tumor 
is not only possible but probable when the embryonic cells, under the influ- 
ences of local or general causes, assume active tissue-proliferation, and 
their migration is permitted by a diminished physiological resistance on 
the part of the adjacent tissues. 



IX. DIAGNOSIS OF TUMORS. 

The diagnosis of tumors is a science and an art — a science, because 
the accurate anatomical localization of a tumor and the correct appre- 
ciation of its character and tendencies presuppose a thorough knowledge 
of anatomy, physiology, and pathology ; an art, because the determina- 
tion of the exact location and character of a tumor often requires deli- 
cate manipulation and the most intelligent application of all known 
diagnostic resources. The accurate eye and the trained sense of touch, 
the tactus crudities, are always at hand, and, as a rule, can be more relied 
upon than can the use of complicated instruments in ascertaining the 
location, extent, and pathological characteristics of a tumor. Prac- 
tical instruction at the bedside and examination of patients under super- 
vision of the teacher will accomplish more in rendering the student 
familiar with the means of diagnosis than will the most painstaking 
didactic teaching. An abundance of clinical material and thorough 
and systematic examination by the students of the cases presented are 
absolutely necessary in acquiring the necessary diagnostic skill. The 
writer knows of no department of surgery more difficult to teach and 
to comprehend. The interest of the student can be awakened and his 
senses be trained properly only by bringing him in contact with patients 
and by encouraging him in making thorough and systematic examina- 
tions. Oncology is usually imperfectly taught in our medical colleges ; 
this fact will go far in explaining the lack of interest of our students 
in this, to them, perplexing subject. 

Clinical History. — In each case of suspected tumor the clinical 
history should be investigated carefully. A failure to carry out prop- 
erly this, the initial, part of the diagnostic work has led many a distin- 
guished surgeon astray in making a distinction between an inflamma- 
tory swelling and a tumor. Every surgeon inquires almost instinctively 
into heredity as a possible factor in the production of a tumor. It is 
not only necessary to ascertain the existence of an hereditary influence 
in the parents, but the investigation must be carried farther back, as we 
have seen that this element may not assert itself in the offspring, but 
may appear again in the second, third, or fourth generation. It is also 
necessary to determine the existence of heredity in more distant mem- 
bers of the family — uncles, aunts, cousins, and nephews — as heredity 

89 



90 PATHOLOGY AND TREATMENT OF TUMORS. 

does not descend on all members of a family in the same degree, as is 
shown by the statistics quoted on this subject. The existence of tumors 
in different members of the family and in related families of two or more 
generations should be noted in estimating heredity as a possible etio- 
logical factor. 

Length of Time Tumor has Existed. — This part of the clinical 
history is often indefinite and misleading. A tumor has often existed 
for years before being accidentally discovered by the patient or the phy- 
sician. Patients generally fix as the date when the tumor appeared 
the time when it was accidentally discovered. By relying on the pa- 
tient's statement in regard to the time the tumor commenced the sur- 
geon is liable to mistake a benign tumor for a malignant tumor or an 
inflammatory affection. Due allowance must therefore be made in ref- 
erence to the statements made by patients or their friends as to the 
length of time a tumor has existed. 

Location of Tumor. — In eliciting from the patient the clinical his- 
tory it is very important to ascertain from him, so far as possible, the 
exact location of the tumor when it was first noticed. The student 
should be made to appreciate the importance of the questions put to 
the patient to elicit this part of the clinical history. In investigating 
the probable starting-point of a large abdominal tumor it is quite im- 
portant for us to ascertain from the patient whether the tumor was first 
noticed above the pelvis or about the pelvic brim, and on which side. 
In a rapidly-growing ulcerating tumor of the neck the patient's state- 
ments will often render material aid in making a differential diagnosis 
between secondary glandular carcinoma and lympho-sarcoma. In the 
absence of an appreciable source of carcinomatous infection the patient, 
upon questioning him properly, will probably make the statement that 
the first thing he noticed was a movable, painless tumor under the skin. 
This information alone from an intelligent patient will exclude a surface 
carcinoma. An epiblastic surface tumor commences in the skin, and 
the patient's statement will often impart valuable information in dif- 
ferentiating between an ulcerating malignant tumor of the epiblast and 
one of the mesoblast. The relation of the skin or the mucous membrane 
to the tumor in its early stages must be ascertained from the patient for 
the purpose of enabling the surgeon to connect the tumor with its matrix, 
derived from the different germinal layers, in all cases in which any doubt 
remains as to the Jdstogcnctic source of the tumor. 

Rapidity of Growth of Tumor. — The rapidity with which a tumor 
has increased in size should be taken carefully into account in the dif- 
ferential diagnosis between a tumor and an inflammatory swelling and 
between a benign and a malignant tumor. We know how unreliable 



DIAGNOSIS OF TUMORS. 91 

the statements of patients are in ascertaining the previous clinical course 
of a tumor. The patient must be requested to compare the size of the 
tumor when first discovered with objects familiar to him, such as a 
hempseed, a pea, a bean, a hazelnut, a walnut, a hen's egg, a plum, 
an apple, an orange, a cocoanut, a child's head, an adult's head, etc. 
By comparing the size of the tumor when first discovered with its present 
size and estimating the time that has elapsed zee arc in possession of facts 
which enable us to judge, at least in an approximately correct way, the 
rapidity of grozoth of the tumor. As a rule, a benign tumor grows slowly, 
a malignant tumor rapidly ; the clinical behavior of a tumor is therefore 
very important in making a differential diagnosis between benign and 
malignant growths. 

Pain. — Spontaneous pain was regarded for a long time as one of 
the most distinctive clinical witnesses of carcinoma as compared with 
benign growths. The idea that carcinoma is an exceedingly painful, 
torturing disease is deeply rooted among the people of all nations. 
A peculiar lancinating, paroxysmal pain with nocturnal exacerbations 
has been described since the time of Hippocrates as characteristic of 
carcinoma. Physicians and surgeons have placed too much stress upon 
the diagnostic value of this symptom. A lancinating pain at variable 
intervals and only of a moment's duration is described by many patients 
suffering from carcinoma of the breast and epithelioma of the lip, but 
is by no means a constant symptom. The writer is sure that clinical 
observations will bear him out in making the statement that adenoma 
of the breast causes more suffering than docs carcinoma of the same 
organ and of the same size. He has known of numerous cases of car- 
cinoma of internal organs in which the disease was painless from the 
beginning to the end. Sarcoma, as a rule, causes less pain than car- 
cinoma. Benign tumors, with the exception of tumors of the nerves 
or of their sheaths, produce pain only when, from their location or their 
size, they cause compression of a sensitive nerve. A small osteoma in 
the bony canal through which pass certain sensitive nerves will occasion 
excruciating pain, while a lipoma in the panniculus adiposus, of immense 
size and meeting with no resistance to its outward growth, will remain 
a painless affection throughout life. 

Tenderness. — The pain produced by pressure results from com- 
pression of a sensitive nerve subjected to the pressure. Tumors of 
the nerves or of the nerve-sheaths most frequently give rise to pain 
on pressure. The subcutaneous painful tubercle is well known as the 
most sensitive tumor. Tumors of the nerve-sheaths of the terminal 
nerves in the subcutaneous tissue, described by Recklinghausen, are 
not painful on pressure, owing to the looseness of the structures in 



92 PATHOLOGY AND TREATMENT OF TUMORS. 

their immediate vicinity. Tenderness in carcinoma and sarcoma depends 
either on some unusual relation of the tumor to sensitive nerves or to 
the existence of complications, as pain is absent in the majority of cases 
of uncomplicated malignant tumors. Tenderness is an exceedingly im- 
portant symptom in differentiating between a tumor and an inflammatory 
swelling, being usually absent in the former, and almost invariably pres- 
ent to a greater or less extent in the latter. 

Examination of the Patient. — The surgeon who limits his examina- 
tion to the tumor docs not do his duty to his patient, and is very liable to 
commit mistakes in diagnosis, prognosis, and treatment. A correct diag- 
nosis implies more than a mere classification of the tumor for which 
the patient seeks relief: it includes a careful inquiry into the condition 
of every important organ, the elucidation of the exact pathological 
conditions in the tumor itself, and a careful investigation of its environ- 
ment. A correct diagnosis should furnish all the clinical and patho- 
logical data required to guide the surgeon in rendering a reliable 
prognosis and in adopting a safe and judicious course of treatment. 
Specialists in surgery are very apt to overlook the importance of a 
thorough and unprejudiced examination of the patient as the first step 
in seeking reliable evidence upon which to build a correct diagnosis. 
The age of the patient is of some importance in determining the prob- 
able character of the tumor, as it has been shown that benign tumors 
are met with most frequently in persons not past middle life, while 
malignant tumors, on the whole, attack persons advanced in years. In 
this respect sarcoma constitutes frequently an exception, as it exempts 
no age, being sometimes found in children less than ten years of age, as 
well as in persons far advanced in years. It must not be forgotten, how- 
ever, that carcinoma occasionally is met with in young persons. The 
writer has seen carcinoma of the rectum in a boy eighteen years of age, 
carcinoma of the stomach in a man twenty-seven years old, carcinoma 
of the breast in a female aged thirty, and carcinoma of the lip in a man 
thirty-five years old. Sex, as we have seen, predisposes to tumors, both 
benign and malignant, of special organs. This can also be said of 
certain occupations. The general appearance of the patient often 
enables the experienced surgeon at first sight to make a probable 
diagnosis between a benign and a malignant tumor. The wasting of 
the subcutaneous adipose tissue and the sallow complexion of the face 
are familiar to the surgeon as indicating far-advanced malignant disease. 
CEdema about the ankles and over the sternum is an indication pointing 
in the same direction. Occasional hemorrhages from different organs, 
as the kidneys, the bladder, the vagina, and the rectum, frequently call 
the attention of the surgeon to these organs as the probable seat of a 



DIAGNOSIS OF TUMORS. 93 

malignant tumor. Mechanical obstruction in the different hollow vis- 
cera in persons past middle life is caused more frequently by malignant 
tumors than by all other causes combined. Functional disturbances of 
all kinds must be investigated carefully and traced to the primary cause. 
Neuralgic pain caused by tumor-pressure will often lead to the detec- 
tion of the tumor. Obstruction to the venous circulation, if studied 
with the same object in view, will frequently reward the surgeon with 
a similar result. To show the importance of a careful and painstaking 
examination of the patient before venturing a diagnosis based upon a few 
probably unimportant local evidences, attention will be called to a few 
conditions which frequently present themselves to the surgeon. Let 
us suppose a patient presents himself suffering from a sarcoma of the 
intermuscular fascia of the forearm. The tumor has attained the size 
of a cocoanut, is movable, and has no connection with the overlying 
skin. The patient's general health is not materially impaired. The 
rapidity of the growth of the tumor, its shape, and its consistence 
render the diagnosis of sarcoma more than probable. The surgeon 
has determined in his own mind that an amputation affords the only 
chance to effect a radical operation with a view of preventing a recur- 
rence in the future. Before informing the patient of his intentions he 
takes the necessary pains to look for contraindications. On further 
examination he finds a slight convergent strabismus, the liver enlarged 
and nodular, and traces of albumen in the urine. The result of this 
additional examination has satisfied him that operative interference of 
any kind is positively contraindicated, as general dissemination has 
already taken place, important organs being implicated. The exam- 
ination into the condition of the important organs has been the means 
of saving the patient the pain, anxiety, and risks to life incident to a 
useless operation, and has prevented the infliction of additional reproach 
upon modern surgery. 

Let us suppose another case : A patient advanced in years presents 
himself with a lipoma over the shoulder which has given him but little 
inconvenience, but which he is anxious to have removed. As the 
patient's general health, upon superficial examination, does not appear 
to be impaired, the surgeon responds to the request of the patient. 
The patient is anesthetized and the tumor is removed. Suppression 
of urine follows the operation. The patient is seized with uremic con- 
vulsions and dies comatose. A post-mortem examination reveals the 
existence of a chronic interstitial nephritis. A careful examination of 
the urine would have furnished a positive contraindication to an opera- 
tion, and would have been the means of preventing a premature death 
from the immediate effects of the anesthetic. 



94 PATHOLOGY AND TREATMENT OF TUMORS. 

In calling special attention to the importance of searching for con- 
traindications to radical operations for carcinoma another hypothetical 
case will be alluded to : A woman about middle life presents herself 
for the removal of a carcinomatous breast. The disease in the organ 
primarily affected has advanced to such an extent that the breast is 
firmly attached to the chest-wall ; infiltration of the axillary glands is 
moderate ; the patient's general health is not much impaired. She is in 
the hands of a careful, conscientious surgeon. The breathing attracts 
his attention ; it is short and frequent. He makes a careful physical 
examination of the chest, and finds a copious effusion in the pleural 
cavity on the side corresponding with the diseased breast. If he had 
any intention whatever to advise operative interference, this will soon 
be abandoned, as he has satisfied himself that the disease is beyond the 
reach of an operation, as shown by the existence of a hydrothorax 
caused by extension of the disease through the chest-wall to the 
parietal pleura. 

The hypothetical cases cited do not represent imaginary complica- 
tions, but illustrate many similar cases which the surgeon is called 
upon to examine and treat, and they speak for themselves in showing 
the importance of subjecting tumor-patients to a thorough examination. 

Examination of the Tumor. — The examination of a tumor should 
be made in a systematic manner. Much information can be gained by 
the intelligent use of the sense of sight. Ocular examination is ex- 
tended by the use of the ophthalmoscope, the otoscope, the rhino- 
scope, the laryngoscope, the urethroscope, the cystoscope, and by the 
employment of different specula in the examination of tumors in local- 
ities inaccessible to inspection without the aid of these instruments. 
Inspection enables the surgeon in the examination to gain information 
concerning (i) color, (2) size, (3) form and structure of surface, (4) loca- 
tion, and (5) transmission of light. 

Color. — The color alone often distinguishes the character and struct- 
ure of the tumor. In angioma of surfaces accessible to inspection the 
color of the tumor will enable the surgeon to distinguish between the 
venous and the arterial variety. The venous angioma resembles in its 
color venous blood ; the arterial angioma, that of arterial blood. The 
pigmentation of a sarcoma or a carcinoma distinguishes these most 
malignant of all tumors from the other varieties of malignant tumors. 
Discoloration of the surface of a tumor is also caused by interstitial 
hemorrhage and by inflammation. 

Size. — The size of a tumor is significant to the surgeon, because 
certain tumors never exceed a definite size. Neuromata and osteomata 
never reach large size. They grow slowly, and when they attain the 



DIAGNOSIS OF TUMORS. 95 

maximum size they remain stationary throughout life. Very important 
from a diagnostic standpoint is a sudden variation in size. This is 
observed in vascular tumors, which under the influence of certain 
agencies that cause intravascular tension increase in size and become 
firmer. A nsevus in a child becomes more prominent and tense 
during the act of crying. The volume of a large venous tumor is often 
materially affected by respiration, the size increasing during expiration 
and diminishing during inspiration. In following the clinical history of 
a tumor careful measurements should be taken and recorded from time 
to time. The eye should not be relied upon in ascertaining the increase 
in size of a tumor. Fixed anatomical landmarks are readily available 
guides in following the extension of a tumor toward its vicinity — by 
recording at fixed intervals the measured distance between them and 
the margin of the tumor. When the measurements are taken the 
patient and the part to be examined should always be placed in the 
same position. 

Form and Structure of Surface. — The shape of a tumor can often 
be outlined by inspection, and if the tumor is sufficiently near the sur- 
face, any irregularities in its contour can be recognized at the same time. 
The shape of the tumor is determined largely by the structure of the 
mother-soil, the anatomical locality, and the resistance offered by the 
surrounding structures to the extension of the growth. Equal resist- 
ance on all sides determines a globular shape ; later, pressure results in 
elongation of the tumor ; absence of resistance on one side gives rise 
to a growth in that direction, followed by constriction at the base of the 
tumor and by pedunculation. Central tumors of bone usually assume 
the shape of a spindle. A nodular surface is often presented by carci- 
noma, but it is also found in all tumors which have perforated organs 
and tissues and grow free in all directions. The most malignant forms 
of carcinoma and sarcoma have a smooth surface, owing to the predomi- 
nance of their cellular elements over the stroma. Nodular projections 
in carcinoma as well as in other tumors are produced by contraction of 
the stroma as well as by unequal resistance offered by the surrounding 
tissues. Ulceration on the surface of a tumor represents from an 
etiological standpoint different things : Superficial excoriations are 
usually the outcome of purely local accidental causes, such as trauma 
or the application of irritating remedies, and commonly heal upon the 
removal of the cause ; ulcerated surfaces occupied by a fungous mass 
indicate the existence of a rapidly-growing tumor ; extensive ulceration 
devoid of massive fungous granulations point to the existence of a less 
rapidly-growing tumor ; while deep, and especially crater-like, excava- 
tions are indicative of speedy destruction of the central mass of the 



96 PATHOLOGY AND TREATMENT OF TUMORS. 

tumor. Of special pathological interest is the character of the floor 
of the ulcer — whether it is clean or ragged, red, gray, dirty, or gan- 
grenous ; frequently, characteristic parts of the tumor are exposed on 
the surface of the ulcer. The secretion of the ulcer is of diagnostic 
value in determining the stage of malignant degeneration and the 
character of the microbic infection which followed the exposure of the 
tumor-tissue to the atmospheric air. Suppuration indicates infection 
with pyogenic microbes ; putrefaction of the secretions points to the 
presence of putrefactive bacilli in the dead tissue attached to the sur- 
face of the ulcer. Capillary bleeding from the surface of the ulcer is 
an indication of the destruction of granulations by the tumor-tissue, 
by pathogenic microbes, or by an injury ; more profuse hemorrhage 
results from erosion of the wall of blood-vessels of considerable size. 

Location. — Ocular inspection often reveals the primary location of 
the tumor. A unilateral exophthalmos denotes the presence of a 
retrobulbar tumor; an unusual prominence of one of the cheeks and 
the presence of a projecting tumor of the nose on the same side point 
to the existence of a tumor of the antrum of Highmore. Inspection 
is also useful in some cases in determining the character of the tumor 
— -as, for instance, in the case of tumors of the lower lip, which tumors, 
with few exceptions, are epithelial cancers. 

Transmission of Liglit. — A tumor with clear liquid contents and 
tumors composed largely of a colorless intercellular substance transmit 
light to a greater or lesser extent, rendering them translucent or trans- 
parent — as, for example, hydrocele of the neck, myxoma of the nasal 
cavities, etc. 

Tactile Examination. — Tactile examination is more important than 
ocular inspection in the examination of a tumor. The value of ocular 
examination has been overestimated greatly in the past. In ascertain- 
ing the exact location and extent of a tumor much more diagnostic 
information is gained by the employment of the sense of touch than 
by inspection with the aid of specula, if the tumor is accessible to 
digital examination. The mania on the part of surgeons and instru- 
ment-makers to invent new specula for the exploration of channels and 
cavities accessible to digital exploration has about subsided, and in its 
place efforts are being made to instruct students more efficiently in the 
use of the finger in the examination of tumors. The acquirement of 
the tactus cntditus requires long and careful training. The student 
should be given an opportunity to handle and examine tumors of all 
kinds, in order to familiarize himself with their structure and physical 
characteristics by the sense of touch. Instruction of this kind will 
impart a thorough knowledge of the nature and extent of the degen- 



DIAGNOSIS OF TUMORS. 97 

erative changes which occur in the parenchyma and stroma of tumors. 
The careful digital palpation of the different normal tissues and organs 
is an exceedingly useful exercise in acquiring a delicate sense of touch. 
Fluctuation can be studied advantageously by palpating a bladder or a 
rubber bulb distended by water. In the examination of tumors in the 
living subject the teacher should inform the student what he is expected 
to find and to feel before he proceeds to make the digital examination. 
If the tumor is large, manual examination takes the place of the digital. 
In bimanual examination both hands are employed. Bidigital exami- 
nation means the use of one finger of each hand in the exploration of 
a tumor or other pathological product. The information gained by 
manual and digital examination is often used to corroborate or to 
render more accurate what has been learned from inspection. The 
tactile sense is relied upon in deciding diagnostic points of the greatest 
practical import to the surgeon, the most important being — I. Connec- 
tion of the tumor with the mother-soil ; 2. Resistance and consistence ; 
3. Pulsation; 4. Tenderness ; 5. Crepitation. 

Connection of Tumor with the Mother-soil. — The kind and extent 
of the connection of a tumor with the mother-soil have an important 
bearing on the nature of the tumor and on the selection of appropriate 
operative measures. The degree of mobility of a tumor and the ease 
with which it can be displaced are determined largely by the nature of 
its connection with the surrounding tissues. The wider the base of a 
tumor and the more projections it sends out into the surrounding 
tissues, the more pronounced becomes its immobility and the more 
limited the extent to which it can be displaced. If the tumor is attached 
only by a pedicle, it is freely movable and can readily be displaced. 
Such tumors in the abdominal cavity often become displaced in an 
axial direction, resulting in twisting of the pedicle. If a tumor is sur- 
rounded on all sides by resisting tissue, it is held firmly in place and 
cannot be displaced. The immobility of a carcinoma is due to the 
many prolongations which the tumor sends out into the surround- 
ing tissues. A carcinoma is movable if it involves a movable organ 
before the organ becomes attached by the extension of the tumor 
beyond the limits of the organ primarily affected. Tumors freely 
movable often become firmly attached to the surrounding tissues by 
inflammatory adhesions following inflammation of the tumor resulting 
from direct infection through an ulcerated surface, from auto-infection, 
or from infection caused by exploratory puncture or by ineffective treat- 
ment. A branchial cyst is usually attached loosely to the surrounding 
tissues, and can readily be enucleated, but after ineffectual attempts at 
radical cure by irritating injections or after incomplete removal by 
r 



98 PATHOLOGY AND TREATMENT OF TUMORS. 

enucleation the whole or a part of the cyst-wall is found firmly attached 
to important structures, rendering enucleation impossible and the 
removal by excision a difficult and dangerous procedure. In deter- 
mining the mobility of a tumor its base should be grasped firmly, when 
by moving it in different directions the degree of mobility and the ex- 
tent of its connection with the mother-soil can be determined. If the 
tumor is immediately under the skin or under the abdominal wall, the 
existence of attachments to the skin can be ascertained by gliding the 
superimposed structures over the surface of the tumor; adhesions between 
an abdominal tumor and the anterior abdominal wall can be ascertained 
by observing the respiratory movements of the abdominal wall, or, if the 
tumor is not too large, by displacing it by changing the position of the 
patient or by moving it with the hands. The absence of inflammatory 
adhesions or of neoplastic attachments of a struma to tissues other 
than the underlying trachea is demonstrated by the movements 
imparted to the tumor by the trachea during deglutition. The extent 
and location of attachments of tumors in some of the cavities — for 
instance, the uterine cavity and the nasal passages — can often be deter- 
mined only by a careful use of probes and sounds. It can be laid down 
as a rule that the more limited are the attachments of a tumor with the 
surrounding tissues, the more favorable is the prognosis and the bet- 
ter are the results following its operative removal. In the absence of 
inflammatory processes, attachment of the tumor to the underlying 
skin indicates that the tumor is malignant. The lymphatic glands in 
the region occupied by a tumor should always be subjected to a careful 
examination. Enlargement of the lymphatic glands in the vicinity of 
a tumor must always be regarded with suspicion. A consensual hyper- 
plasia of the lymphatic glands may occur in consequence of the intro- 
duction into the lymphatic channels of pathogenic microbes through 
the ulcerated surface of a benign tumor. In the absence of a tangible 
infection-atrium implication of the regional lymphatic glands, with few 
exceptions, points to a malignant nature of the tumor. As lymphatic 
infection seldom accompanies sarcoma, when this condition exists inde- 
pendently of microbic infection the primary tumor in the great majority 
of cases is a carcinoma. 

Resistance and Consistence. — Resistance and consistence are vari- 
able qualities of tumors. We seek to ascertain the density of a tumor 
by fixing its base, and then ascertain its resistance to finger-pressure 
at different points. To ascertain the density of a deeply-situated tumor 
or of different parts of the same tumor, Middeldorpf advised the use of 
acupuncture needles (Fig. 36), and he applied to this diagnostic aid the 
term akidopeirastic. The writer has found this diagnostic resource of 



DIAGNOSIS OF TUMORS. 



99 



great value in the differential diagnosis of deeply-seated tumors of bone. 
If the tumor is an osteoma, the needle will be arrested when it reaches 
the surface of the tumor; if it is a periosteal sarcoma, the needle will 
penetrate the soft parts of the tumor, and with its point plates or 
spiculae of bone can usually be detected. If it is a central osteo- 
sarcoma, the needle can be forced by pressure and by rotatory move- 
ments through the atrophic 

compact layer of the bone ~~ ~~" &LLLJI]-' 
encasing the tumor, after — Q 

Which it Can be forced FlG - 36.— Acupuncture needles used in exploring tumors by 

through the soft tumor-mass a ' opeiras " c - 

until the opposite side of the bone is reached without meeting with 
any appreciable resistance. Exploratory puncture for this and other 
purposes should be done under strictest antiseptic precautions, other- 
wise puncturing may become the direct cause of infection. The needle, 
before being used, should be sterilized by boiling or by heating it for 
a sufficient length of time in the flame of an alcohol lamp, and the 
surface where the puncture is to be made should be rendered aseptic 
by thorough washing with warm water and soap, followed by washing 
with a strong antiseptic solution. After the removal of the needle the 
puncture should be sealed hermetically with iodoform collodion. The 
existence of cysts in solid tumors can often be determined by the 
same method of exploration. Osteoma and chondroma are the benign 
tumors noted for their density. Fibroma varies greatly in this respect, 
often being nearly as hard as cartilage, in other instances being as soft 
as a myxoma. Uterine fibroids present both extremes as to density. 
A soft fibroma of the uterus usually contains muscle-fibres as the pre- 
dominating histological element, and is generally much more vascular 
than the firm variety, in which we find more fibrous tissue and a less copi- 
ous blood-supply. The density of a malignant tumor is in proportion 
to its benign tendencies. In soft malignant tumors the parenchyma-cells 
predominate, the stroma is scanty, and the vascular supply is abundant. 
The softness of a malignant tumor is in proportion to its malignancy. 
The stroma in such cases is scanty, and the cells are numerous and are 
endowed with a maximum capacity of tissue-proliferation ; the new cells 
find ready access into the surrounding tissues, hence early and exten- 
sive infiltration determines rapid growth and early regional and general 
dissemination. Elastic softness is manifested by many fibrous, fatty, 
and sarcomatous tumors. Owing to the softness of the tumor-tissue 
in many cases of very malignant carcinoma and sarcoma, these tumors 
present on palpation a sense of fluctuation which is exceedingly decep- 
tive, and which in many instances has led the surgeon to puncture or 



IOO 



PATHOLOGY AND TREATMENT OF TUMORS. 



incise such tumors under the belief that the swelling contained the 
products of an inflammation. Pseudo-fluctuation is often elicited in the 
examination by palpation of benign tumors, notably myxoma and lipo- 
ma. Fluctuation is frequently absent in dense cysts, particularly if the 
cyst-wall is of unusual thickness. 

The existence of a cystic tumor or swelling and the occurrence of 
cystic degeneration in solid tumors can often be determined only by the 
use of an exploratory needle (Fig. 37) or a trocar. The ordinary hypo- 



4laiU 



Fig. 37. — Exploratory needle. 



dermic needle answers an excellent purpose in ascertaining the presence 
of liquid contents in a cyst. Syringes are, however, very liable to get out 
of order, and this is more particularly the case on occasions when they 




Fig. 38.— Senn's exploratory syringe. 



are most needed. Another objection to the use of the hypodermic and 
the exploratory syringe is the difficulty experienced in securing and 
maintaining them in an aseptic condition ; and, lastly, it is difficult, if not 



DIAGNOSIS OF TUMORS. 1 01 

impossible, to hold the needle perfectly steady while the piston is with- 
drawn in aspirating the contents of the cyst. These objections to the 
use of the ordinary syringe in withdrawing the contents of tumors or of 
swellings apply with special force to exploration of the brain, the peri- 
cardium, and the pleural cavity. The writer, who has for a long time 
been anxious to do away with the piston as a means of aspiration and 
in making intra-articular and parenchymatous injections, has succeeded 
at last in devising an instrument possessing all the merits of the ordi- 
nary syringe, minus the objections to the piston. This instrument is 
also used exclusively in making intra-articular and parenchymatous 
injections. The fluid is withdrawn by aspiration performed by a strong 
rubber bulb in place of a piston, and in making injections the fluid is 
propelled by a column of elastic air. The remaining part of this 
syringe can readily be understood from Figure 38. Some care is neces- 
sary in preventing serious complications arising from the employment 
of this exceedingly useful diagnostic aid. The usual strictly antiseptic 
precautions should never be neglected, as tumor-tissue is very suscep- 
tible to infection, and in a great many cases the use of the exploring- 
needle in the hands of careless practitioners has resulted in serious and 
fatal complications. The puncture should be made after the skin has 
been withdrawn to one side, so that after the withdrawal of the needle 
the puncture in the deep parts will be subcutaneous. Injury to import- 
ant vessels and nerves should be avoided. In puncturing abdominal 
tumors and swellings the needle should be inserted, if possible, extra- 
peritoneally ; if this cannot be done, the puncture in the cyst-wall 
should be oblique, so that upon the removal of the needle there will 
be less liability of the contents escaping into the peritoneal cavity 
through the puncture. In such cases the needle used should be small. 
The removal of a considerable portion of cyst-contents will diminish 
tension, and thus prevent leakage through the puncture. The explor- 
ing-needle can also be used to ascertain the degree of density of the 
tissues which it penetrates (akidopeirastic). If the contents of a sus- 
pected cyst fail to escape on making aspiration, the point of the needle 
is further advanced or withdrawn while aspiration is frequently made 
until the point of the needle is within the cyst. It may also become 
necessary to remove the needle and to insert it through the same 
external puncture in different directions before the cyst is reached. 
The character of the fluid withdrawn will throw much light upon the 
nature of the tumor. If no fluid is withdrawn, we often find in the 
lumen of the needle fragments of tissue, which, when examined under 
the microscope, will furnish valuable information in reference to the 
nature of the tumor. The exploratory syringe is a most valuable, and 



102 PATHOLOGY AND TREATMENT OF TUMORS. 

often an indispensable, instrument in the differentiation between a tumor 
and an inflammatory swelling. 

Pulsation. — Pulsation is felt in certain tumors by placing the palmar 
surface of the hand against the tumor. Not all pulsating tumors are 
vascular tumors. A solid tumor resting against a large artery receives 
the impulse from the artery. In such cases the pulsation can be felt only 
in one direction, away from the artery. A pulsating tumor, angioma, 
vascular myeloid sarcoma, diminishes in size under pressure, and the 
pulsations are not limited to one direction. 

Tenderness. — The causation of pain by finger-pressure over the 
tumor has already been alluded to as an evidence in the diagnosis of 
a tumor. Tenderness indicates either that the tumor is intimately con- 
nected with a sensitive nerve or that the tumor has become infected and 
is the seat of an inflammation. Under ordinary circumstances pressure 
over a tumor does not cause pain. 

Crepitation. — Palpation of a tumor occasionally elicits a sense of 
crepitation. If the crepitation is caused by the presence of chalky 
masses or bone, it is rough ; if the plates of bone are thin, it is softer, 
resembling the crepitation produced by the bending of parchment. 
The " parchment " crepitation is produced by making pressure upon 
a myeloid sarcoma in which the compact layer of the bone has been 
reduced to thin plates or scales by pressure from within outward, and 
in chondroma surrounded by a thin, yielding shell of bone. 

Auscultation and Percussion. — The ear, aided or unaided by the 
use of the stethoscope, can be utilized in the diagnosis of certain 
tumors. Percussion is useful in the differential diagnosis of hernia and 
of tumors occupying localities the most frequent seat of hernia. Per- 
cussion is also useful in outlining a tumor in the chest and in the 
abdominal cavity. 

Auscultation is resorted to in the examination of pulsating tumors, 
in which usually, a distinct bruit can be heard, and in the differential 
diagnosis of aneurysm and of tumors located in close proximity to a 
large artery. It must be remembered that a blowing, rasping sound 
is often produced by the narrowing of the lumen of a large artery 
from outward pressure caused by a tumor. 

The diagnostic resources which have been described so far are 
ample, if carefully and thoughtfully applied, to enable the surgeon in 
the majority of cases to make a correct diagnosis. In obscure cases 
it is advisable to repeat the examination at intervals of a few days, 
weeks, or months, and at the same time to observe carefully the clinical 
course of the tumor. A hasty diagnosis in obscure cases is justifiable 
only in urgent cases demanding prompt surgical interference. Whenever 



DIAGNOSIS OF TUMORS. 10, 

permissible, the surgeon should take sufficient time and, if necessary, mak 
repeated examinations, and exhaust all diagnostic resources before h 
commits himself concerning the nature of the tumor. 

It remains to discuss — 

The Value of the Microscope as an Aid in the Diagnosis 01 
Tumors. — There is no doubt in the mind of the writer that the valu> 
of the microscope as an aid in the diagnosis of tumors has been greatb 
over-estimated. The greatest blunders in diagnosis and treatment hav 
been committed by surgeons of eminence through placing too grea 
reliance on the microscopic examinations of fragments of tumor-tissui 
obtained either before operation or from the specimens removed. Th 
late Emperor Frederic of Germany is a case corroborating the trutl 
of this assertion. His attending surgeon, Von Bergmann, made a cor 
rect diagnosis, basing his opinion upon the clinical aspects of the case 
A part of the tumor was removed and examined by the most dis 
tinguished pathologist the world has ever seen. His diagnosis wai 
based upon what he could see under the microscope. In the sec 
tion examined he could detect nowhere any evidences of malignancy 
The epithelial cells, greatly increased in number, retained their norma 
relation to the underlying tissues. All the pictures under the micro- 
scope represented a benign papilloma. The disease, however, pursuec 
its relentless course, notwithstanding the favorable prognosis made 
and in a few months destroyed the life of the illustrious patient. The 
unprejudiced surgeon will readily understand the source of fallacy ir 
the diagnosis made by the pathologist. The part removed and exam- 
ined represented only one part of the tumor. The attached deep por- 
tion contained the carcinoma-cells, and it was from this part that the 





Fig. 39. — Warren's harpoon for the removal of tissue from solid tumors for microscopic examination. 

disease extended from one tissue to another. The case is an extremely 
valuable one in showing the importance of examining different parts 
of a tumor if the microscope is to be relied upon in making a final 
diagnosis. The examination under the microscope of isolated cells is 
not to be relied upon, as all the varieties of tumor-cells have their 
counterpart somewhere in the normal tissues of the body. Instruments 
constructed upon the plan of a trocar have been devised by Wintrich, 



io4 



PATHOLOGY AND TREATMENT OF TUMORS. 



Bouisson, Bruns, Middeldorpf, and J. Collins Warren (Fig. 39), for the pur- 
pose of removing particles of tumor-tissue for microscopic examination. 
The objection to this method of obtaining tissue for examination is that 
by taking the tissue from only one part of the tumor the part removed 
may not represent tumor-tissue, and may consequently lead to error 
in diagnosis ; and multiple punctures are objectionable, as they are 
likely to give rise to considerable hemorrhage and to stimulate tumor- 
growth. This method of procedure is, however, advisable when all 
other diagnostic resources have failed and it is essential for the welfare 
of the patient that a correct diagnosis should be made before an opera- 




Fig. 4 o.-Gurama of the liver (after Karg and Schmorl). In the centre of the field circumscribed foci, 
niliary gnmmata ; the same are composed of young granulation-tissue, and show in their centre evidences 
f degeneration. The parenchyma-cells are seen as grayish-black stripes, and are separated from each other 
iy narrower stripes of cellular connective tissue. 



ion is undertaken. Preparations of teased tissue are of but little value 
or diagnostic purposes. The fragment should be prepared properly, 
md from it sections should be taken for microscopic examination. 



DIAGNOSIS OF TUMORS. 



io 5 






&*, 







106 PATHOLOGY AND TREATMENT OF TUMORS. 

Only specimens which represent both cells and stroma in their proper 
relations enable the microscopist to interpret the character of the tumor. 
How difficult it is to distinguish the tissue of some tumors from the 
granulomata by the aid of the microscope can readily be seen by a 
glance at Figures 40, 41, and 42. All these illustrations represent in 
the foreground embryonic connective tissue with a very scanty stroma. 
Without knowing anything about the clinical aspects, it will readily be 
seen that it would be exceedingly difficult to distinguish between a 
small round-celled sarcoma, young granulation-tissue, and a gumma. 
It is in just such cases that we seek additional light from a micro- 
scopic examination. 

To illustrate still further the danger which may follow the use of 
the microscope as an exclusive and only means of diagnosis, the writer 
will relate a case which recently came under his observation. During 
the World's Fair held in Chicago he was consulted by a Russian 
gentleman concerning several tumors which had developed in the scar 
of an operation-wound. He gave the following history : Age, forty ; 
married ; the father of several healthy children ; merchant by occupa- 
tion. In 1890 he noticed a swelling in the skin at a point corre- 
sponding to the supraspinatus fossa of the right scapula. The tumor 
was movable and painless, but increased quite rapidly in size. He 
consulted his family physician in Russia, who pronounced the tumor 
a sarcoma of the skin and sent him to one of the most prominent 
surgeons in Berlin for operation. The Berlin surgeon made a diag- 
nosis of gumma, placed the patient on specific treatment, and removed 
the tumor, more for the purpose of allaying the fears of the patient 
than with the expectation of any benefit being derived from the 
operation. The patient followed the treatment faithfully, but in the 
course of six months a tumor returned in the scar. He consulted the 
same surgeon, who at the patient's special request removed the tumor 
a second time, still claiming that it was not malignant. It was now 
decided to leave the diagnosis in the hands of the most competent 
pathologists. The surgeon sent a part of the tumor to an eminent 
Berlin pathologist, and the patient sent the balance to the foremost 
Paris pathologist. The specimens were subjected to microscopic ex- 
amination, and each pathologist sent in a written report to the effect 
that the tumor was a gumma, and not a sarcoma. The patient was 
now placed on vigorous antisyphilitic treatment, including mercurial 
inunctions, baths, and the internal use of corrosive sublimate and 
potassic iodide in large doses. The wound after both operations healed 
by primary intention. The patient is not aware that he ever con- 
tracted syphilis, and never showed evidences of secondary or tertiary 



DIAGNOSIS OF TUMORS. 



107 



manifestations. When the writer examined the patient none of the 
remote consequences of syphilis were discovered. The pale, large scar 
following the last operation was occupied by four tumors, covered by 
intact scar-tissue and varying in size from that of a hazelnut to that 
of a walnut, all of them perfectly movable, and with no attachments 
to the scapula. If ever a case of sarcoma of the skin was seen, this 
was one. Under the circumstances it was deemed prudent to advise 
the patient to return to his surgeon for a third operation. The writer 
does not wish to under-estimate the value of the microscope as an aid 
in the diagnosis of doubtful tumors, but he must insist that it cannot 
be relied upon in differentiating between a small round-celled sarcoma 
and some of the granulomata under circumstances such as those 
detailed above. In doubtful tumors of accessible surfaces tumor-tis- 
sue can be selected and removed 
for microscopic examination. Sec- 
tions of such specimens are better 
adapted for diagnosis by means 
of the microscope than fragments 
taken from the depths of tumors 
through the skin with the different 
forms of harpoons. Another course 
is sometimes necessary when the 
surgeon has decided to remove the 
growth and is in doubt as to its 
nature. Here the microscope is em- 
ployed during the operation as an 
aid in diagnosis. As soon as the 
tumor is reached, when doubt still remains as to its character, a piece is 
removed and sections are made with a freezing microtome (Fig. 43) for 
microscopic examination. The freezing microtome can be purchased at 
a small expense, and should have a place in the operating-room of every 
hospital. The result of such an examination frequently settles all doubt 
as to the nature of the tumor, and serves as a valuable guide to the 
surgeon in the performance of the operation. The microscope is an 
invaluable aid in the diagnosis of tumors, but the conclusions based upon 
the results of the examination are not infallible ; hence the importance of 
a careful study of the clinical aspects of the tumor, followed by a thorough 
examination of the patient, of the tumor, and of its environments. 




Fig. 43. — Freezing microtome. 



X. PROGNOSIS OF TUMORS. 

A reliable prognosis presupposes a correct diagnosis. To predict 
correctly the probable termination of a tumor requires an accurate 
knowledge of its life-history and of its relations to its neighborhood 
and to the entire organism. The prognosis must therefore rest largely 
upon a careful study of the clinical history of the tumor, its anatomical 
location, its influence upon the adjacent tissues, and the general condi- 
tion of the patient. It is when we are called upon to foretell the future 
behavior of a tumor that we realize most keenly the necessity of 
making a searching examination of the patient as well as of the tumor. 
From a prognostic standpoint it is absolutely necessary to divide all 
tumors into the two great clinical divisions (i) benign and (2) malig- 
nant. If we are able in the diagnosis to exclude inflammatory swell- 
ings, the next duty that presents itself is to differentiate between 
benign and malignant tumors. This task is easy in some cases, diffi- 
cult or impossible in others. A carcinoma that has advanced to the 
stage of ulceration with regional glandular infection is recognized at 
sight ; a rapidly-growing tumor in bone or in periosteum in localities 
predisposed to sarcoma is readily identified as such. Under other less 
obvious circumstances the question as to whether the tumor is benign 
or is malignant is not so easily decided. Carcinoma of some of the 
internal organs is often diagnosed only in the post-mortem room. 
Carcinoma and sarcoma of accessible organs are frequently recognized 
as such only after their clinical behavior has given unmistakable evi- 
dence of their malignant character. It is evident that the surgeon 
who regards his own reputation and the welfare of his patient must be 
cautious in rendering his verdict as to the probable course the tumor 
will pursue in the future and the ultimate fate of his patient. The 
prognosis should be postponed until repeated examinations — and, if 
necessary, the microscopic examination of tissue from the tumor — have 
furnished conclusive evidence of the nature of the tumor. It is most 
humiliating to a surgeon to make a diagnosis of malignant disease, and 
to render a prognosis in accordance with his views of the nature of the 
tumor, and to find later, by its clinical course, that it was either a 
benign tumor or an inflammatory swelling. It is a disregard of a duty 
imposed upon a surgeon to pronounce a malignant tumor non-malig- 

108 



PROGNOSIS OF TUMORS. 1 09 

nant upon a superficial, hasty examination, as the loss of time may 
weigh heavily in the balance of failure of a too-long-postponed radical 
operation. It must be apparent to the student that an intelligent, reliable 
prognosis must necessarily rest on a correct diagnosis, and that a prog- 
nosis should consequently be withheld from the patient and his friends 
until the nature of the tumor has been ascertained by conclusive evidence. 
A correct diagnosis having been made, the next question that pre- 
sents itself to the conscientious surgeon is, To what extent should the 
knowledge gained as to the nature of the tumor be communicated to 
the patient and his friends ? The prognosis in cases of benign tumors 
should be freely and candidly expressed to the patient, including the 
possible risks of an operation and its probable result. A different 
course should be pursued if the tumor is malignant. Under ordinary 
circumstances the writer regards it in the light of a cruelty to inform 
a patient directly that he is suffering from a malignant tumor. The 
public appreciates our shortcomings in the treatment of malignant 
tumors, and with few exceptions an intelligent patient regards such 
a diagnosis as his death-sentence. The mental depression following 
such a declaration not only destroys all happiness on the part of the 
patient, but has a disastrous effect on the disease, and is an important 
factor in detracting from the immediate and remote results of an 
operation. The surgeon is often placed in a very unenviable position 
when importuned by the patient in reference to the nature of the 
growth. The question, "Have I a cancer?" is often squarely put to 
him, and the reply will either inspire hope or cause a despondency 
from which the patient will never recover completely. It has been an 
invariable rule with the writer to inform the relatives as to the true 
nature of the tumor, and to discuss with them the propriety of an 
operation as well as its probable immediate and remote results. The 
patient is informed that he is suffering from a tumor, and this statement 
will prove satisfactory in the majority of cases. If asked as to the 
possibility of a recurrence, the facts are placed as gently as possible 
before the patient. If " ignorance is bliss," this adage has a special 
significance in the case of a patient suffering from a malignant tumor. 
If the patient is not aware that he is suffering from what is regarded 
almost universally as a fatal malady, an operation inspires hope, and, 
in place of the despondency often bordering on desperation that 
attends a knowledge of the true nature of the tumor, the patient 
looks forward to a complete and permanent recovery. The surgeon 
should communicate to the patient's nearest relatives or friends the true 
nature of the tumor and the probable results of an operation, but such 
information shotdd be withheld from the patient himself under ordinary 



no 



PATHOLOGY AND TREATMENT OF TUMORS. 



circumstances. There are exceptions to every rule, and circumstances 
may arise which make it imperative on the part of the surgeon to tell 
the patient the whole truth. 

From an anatomical standpoint every tumor is benign in proportion 
to its degree of isolation from the adjacent tissues and from the organ- 
ism. Benign tumors, as a rule, are encapsulated; consequently they 
remain permanently as local affections having no connection whatever 
with the organism. The encapsulation of some forms of sarcoma is 
more apparent than real, as the capsule does not afford protection 
to the surrounding tissues against invasion by tumor-cells ; yet when 
a capsule is present it imparts to the tumor a certain degree of benig- 
nancy which is not observed in malignant tumors entirely devoid of a 
capsule, as is the case in carcinoma and in the most malignant varieties 
of sarcoma. For reasons that have been explained, the soft, vascular 
tumors belonging to the malignant type of tumors manifest the great- 
est degree of malignancy. In tumors of this kind the stroma, which 
always acts more or less as a barrier to local and general dissemina- 
tion, is always scanty and sometimes is nearly wanting. The cells 
remain in their embryonic state, possess ameboid movements, and are 
reproduced with great rapidity. Such tumors resemble inflammation 
very closely, and the surgeon is familiar with the well-known clinical 




Fig. 44. — Carcinoma of mammary gland, showing numerous leucocytes between tumor-cells and along 
the course of blood-vessels (Surgical Clinic, Rush Medical College) : a, carcinoma-cells ; b, stroma; c, brown- 
ish granules of blood-pigment ; d, area of new proliferation ; e, leucocytes. 



fact that the nearer the anatomical and clinical aspects of a tumor 
correspond with inflammation, the greater its malignancy. In rapidly- 



PROGNOSIS OF TUMORS. ill 

growing malignant tumors we find between the tumor-cells and in 
the course of blood-vessels a picture closely resembling inflammation 
(Fig. 44). 

The immigration of blood-corpuscles into the parenchyma of a tumor 
is caused by the imperfect development of the wall of the new blood- 
vessels and by the favorable local conditions in the interior of the blood- 
vessel for mural implantation. The imperfect wall of the blood-vessels 
in the tissues of malignant tumors corresponds to the damaged capil- 
lary walls in inflamed tissue, and permits the escape of numerous 
leucocytes, and in some cases of red corpuscles. Rhexis is of frequent 
occurrence in rapidly-growing carcinoma and sarcoma. The new cells 
in soft vascular malignant tumors possess ameboid movements in the 
highest degree, and encounter few obstacles on their way from the 
tumor into the surrounding tissues with greatly impaired physiological 
resistance. Cells originating under such circumstances are very liable 
to lose their connection with the mother-soil and to wander away 
into the surrounding tissues or to enter the lymphatic vessels or the 
blood-vessels, thus giving rise to early regional and general dissemina- 
tion. The intrinsic danger of a tumor consists in its capacity to impli- 
cate the adjacent tissues and the organism — that is, in its giving rise to 
regional and general infection. This capacity is possessed to the highest 
degree by the soft vascular carcinomata and sarcomata — tumors that are 
in contact with the surrounding tissues from the beginning, without any 
attempt at the formation of a barrier between abnormal and normal tissue. 

In carcinomatous tumors location plays an important part in deter- 
mining the degree of malignancy of a tumor. For years it has been 
believed and taught by authors and teachers that for some unknown 
reason epithelioma was a less malignant affection than glandular car- 
cinoma, the so-called " scirrhus." For a long time epithelioma was 
described as a tumor separate from carcinoma proper. It was also 
asserted that epithelioma remained as a purely local affection — that 
it did not give rise to regional and general dissemination. A more 
extended and accurate clinical observation of this form of carcinoma 
has convinced pathologists and surgeons that an epithelioma eventually 
becomes diffuse by regional and general dissemination, and destroys 
life in the same manner as a deep-seated carcinoma. The writer has for 
years claimed that the greater benignancy of a surface carcinoma as com- 
pared with a deep-seated carcinoma depends entirely upon its location. 
In epithelioma of the lip, as well as in the case of any other carcinoma 
of a free surface, the tumor can grow only in one direction, while a 
similar tumor located in an organ surrounded by tissues on all sides 
grows from the very beginning in all directions. The field for local 



112 PATHOLOGY AND TREATMENT OF TUMORS. 

infection of a surface carcinoma is therefore limited as compared with 
that of a glandular carcinoma. The increased area of tissue in contact 
with a glandular carcinoma as compared with that of a surface carci- 
noma will readily account for the more constant and earlier occurrence 
of regional infection. Another important element determining earlier 
and more constant regional infection in glandular carcinoma is pressure 
caused by the tissues encroached upon by the tumor. In surface carci- 
noma this element in the diffusion of the tumor is absent, and consequently 
migration of carcinoma-cells into the surrounding tissues is retarded. 

The location of a tumor is also an important factor in estimating 
the danger to life in the case of all benign growths. An osteoma 
on the external surface of the skull always remains as a harmless 
affection, while a similar tumor on the side of the cranial cavity may 
produce distressing symptoms, and may finally result in death from 
cerebral compression. A papilloma on the surface of the skin pro- 
duces no symptoms, while the same kind of tumor in the larynx 
may destroy life by suffocation. A subserous fibroma of the uterus 
becomes a source of danger only from its size, while a small sub- 
mucous tumor is a frequent cause of profuse and even dangerous 
hemorrhage. In connection with the location, the size of a tumor 
must also be taken into consideration in estimating its danger to life. 
Large tumors are prone to undergo various kinds of degenerations 
which in themselves may become a source of danger. A tumor that 
has undergone extensive degeneration is also more likely to become 
infected with pathogenic microbes. Large tumors of the ovary and 
the uterus by displacing abdominal and pelvic organs may cause fatal 
complications by pressure. A similar source of danger attends tumors 
occupying the cranial cavity and the thorax. Large tumors of the 
thyroid gland and malignant tumors of the lymphatic glands of the 
neck become dangerous to life from compression of the trachea. 

A few words in reference to what may be expected from operative 
interference in the treatment of tumors : Complete removal of a benign 
tumor is never followed by recurrence. The same favorable result will 
follow a thorough removal of a sarcoma or a carcinoma if the operation 
is performed before regional infection has taken place. The removal of 
a carcinoma or a sarcoma after regional dissemination has taken place 
is followed sooner or later by recurrence in the great majority of cases. 
Nothing but palliation can be expected from the removal of the primary 
tumor in all cases in -which the disease has become general by metastasis. 

The partial removal of a malignant tumor with extensive regional 
dissemination is often followed by aggravation of the local conditions 
and hastens the fatal termination. 



XI. TREATMENT OF TUMORS. 

The treatment of a tumor must necessarily vary according to its 
nature, structure, and location. The removal of malignant tumors is 
indicated if this can be done before the disease has passed beyond the 
reach of a radical operation. The operation in such instances meets 
an indicatio vitalis, because the intrinsic tendency of a malignant tumor 
is to destroy life. The removal of a benign tumor for a similar indi- 
cation is called for only if the tumor occupies a locality where by its 
presence it produces mechanical conditions incompatible with the func- 
tion of an important organ. In other cases benign tumors are removed 
for the purpose of correcting functional disturbances, for cosmetic 
reasons, and with a view of protecting the patient against the risks 
of a possible transition into a malignant tumor. The treatment of 
tumors divides itself into (i) medical, (2) surgical, and (3) palliative. 

It is superfluous in this connection to make the assertion that a 
rational treatment must be based on a correct diagnosis. It is the 
recognition of the nature, location, and clinical tendencies of tumors 
that distinguishes the honest and competent surgeon from the char- 
latan. The cancer-quack calls every swelling a tumor, and his influ- 
ence among the people is not due to the success he scores in the 
treatment of carcinoma, but is gained by subjecting benign tumors, 
retention-cysts, and inflammatory swellings to a similar barbarous 
treatment, and claiming the results thus obtained as so many victories 
over cancer. We have reason to believe that many of the alleged 
permanent results following operations for malignant disease were cases 
of mistaken diagnosis. Many a gumma and tuberculous ulcer has 
been removed by honest, able surgeons under the belief that they were 
operating for carcinoma. Gummata of bone have frequently been mis- 
taken for sarcoma. The number of permanent results claimed for rad- 
ical operations for malignant disease would be greatly decreased if we 
could eliminate all cases of mistaken diagnosis. Professor von Esmarch 
years ago called attention to the frequency with which tubercular ulcers 
and gumma are mistaken for carcinoma. 

Medical Treatment. 
Since we have learned to distinguish between true tumors and infec- 
tive swellings the indications for medical treatment have almost disap- 

8 113 



H4 PATHOLOGY AND TREATMENT OF TUMORS. 

peared. No kind of internal medication lias any influence whatever in 
limiting tumor-growth, much less in causing the disappearance of a tumor. 
It is interesting for the student to know what has been done in the past 
in the way of internal administration of medicines in the treatment of 
tumors. Mercury was recommended by Boerhaave, and the effects of its 
different preparations were praised by Gama, Akenside, Mariot, Gooch, 
Gmelin, Buchner, Tauchnow, and many others. Rust and his pupils 
had great faith in the use of Zittmann's decoction. Arsenic was intro- 
duced in 1775 by Lefebure in the form of arsenious acid. Fowler's solu- 
tion found many admirers, among them Desault, Klein, Rust, Wenzel, 
Hill, Walshe, Thomson, and more recently Washington Atlee. The 
last-quoted authority had great faith in the internal use of arsenic after 
operations for carcinoma, as he believed the drug had a positive influ- 
ence in retarding, if not preventing, a recurrence. He invariably admin- 
istered this drug after an operation for cancer, and gradually increased 
the dose until it produced slight intoxication, when the use of the drug 
was not suspended, but the dose was diminished. He insisted that if 
patients could not take a drop of Fowler's solution they should be 
given a fraction of a drop ; that is, that the use of the drug should 
be continued under all circumstances and for a long time. Preparations 
of gold were used by Duportail and Duparcque ; the salts of copper, 
by Gauret, Gerbier, Solier, and De la Romillais ; chloride of barium, by 
Crawford and Mittag. Mineral waters, especially those containing prep- 
arations of iodine, enjoyed a good reputation for a long time, and were 
recommended in the highest terms by such men as Wagner, Travers, 
Walshe, Flinsch, Klaproth, Ullmann, Littre, Friese, Copland, and 
Demme. Preparations of iron were regarded with favor by Carmichael 
and Daniel Brainard. Animal charcoal was recommended by Weise 
in 1829. The highest praise was conferred upon conium maculatum 
in its day in the treatment of carcinoma. It was used first for this pur- 
pose in 1 76 1 by Stork ; after him it was recommended in terms of the 
highest praise by Recamier, Neuber, Giinther, Camper, Baudelocque, 
Trousseau, and Solon, and it is extensively prescribed even at the pres- 
ent day by N. S. Davis of Chicago, De Haen, Andree, Fothergill, 
and Alibert. Almost all the narcotics have had their advocates in 
the treatment of carcinoma. The fame of condurango was of short 
duration. Introduced by Bliss of Washington, it soon reached great 
popularity among both laymen and the members of the medical pro- 
fession. Men like Andrews of Chicago and Eichhorst of Zurich ex- 
tolled its merits. Like all other famous cancer remedies, it soon fell 
into well-deserved " innocuous desuetude." Some of the surgeons of 
fifty and a hundred years ago resorted to rigid antiphlogistic treatment. 



TREATMENT OF TUMORS. 115 

Valsalva, Broussais, Brechet, Poteau, Dzondi, and Lisfranc claimed that 
they could eliminate the cancerous material by copious and frequently- 
repeated venesection. Local abstraction of blood was recommended 
by Velpeau. More recently, surgeons aimed to remove the virus of 
cancer by derivatives. After operative removal of the growth setons 
were inserted at different parts of the body. Other surgeons used the 
moxa and blisters to meet the same indication. 

As a matter of historical interest, it should be known that Auzias 
Turenne suggested syphilization to counteract the carcinoma virus. 
We can readily understand why the different mercurial preparations 
commanded the attention and received the approbation of the most 
influential members of the profession for the longest time. Gummata 
diagnosed as carcinoma disappeared under this treatment, and the 
results thus obtained gave the remedy its great reputation. We have 
no authenticated proof that mercury or any of its preparations has ever 
been instrumental in retarding the growth of a tumor. The same can 
be said of all other internal remedies. The internal administration of 
medicines at the present time receives consideration only in the treat- 
ment of some of the complications that may arise and in improving 
the general health of the patient. 

Radical Operation. 

The complete removal of a benign tumor furnishes the best illus- 
tration of what is meant by a radical operation. A radical operation 
for the removal of a tumor has for its object the complete removal of 
tumor-tissue. If this object is attained, the tumor, whether benign or 
malignant, will not return. The removal of a benign tumor generally 
constitutes a radical operation, owing to the structure of the tumor 
and to its complete isolation from the adjacent tissues by a limiting 
capsule. Incomplete removal of a benign tumor is followed by recur- 
rence, in which event the operation does not deserve to be called 
radical, because it failed to accomplish what is understood by the term 
radical. A radical operation undertaken for the removal of a carci- 
noma is radical in the estimation of the surgeon who in dealing with 
the tumor has made every effort to comply with the meaning of the 
word; but in the majority of cases he has been deceived, as is subse- 
quently shown by a local recurrence. The term radical means more 
and more to the surgeon as he becomes more familiar with the path- 
ways and the extent of local and regional infection of malignant tumors. 

Radical operations include — 1. Ligation of the principal blood- 
vessels nourishing the tumor; 2. Galvano-puncture ; 3. Parenchym- 
atous injections; 4. Injection of erysipelas toxines ; 5. Cauterization; 



Il6 PATHOLOGY AND TREATMENT OF TUMORS. 

6. Ligation ; 7. Galvano-caustic wire ; 8. Ecrasement lineaire ; 9. Avul- 
sion ; 10. Extirpation. Most of the modern surgeons resort almost 
exclusively to the use of the knife in undertaking the radical operation 
in the removal of tumors both benign and malignant. The bloodless 
procedures are seldom resorted to, but they deserve a brief description, 
as cases not adapted to extirpation may present themselves, or patients 
may positively object to the use of the knife, and under such circum- 
stances it is wisdom on the part of the surgeon to yield to their request 
rather than to give them an opportunity to seek the services of char- 
latans as devoid of a moral sense of responsibility as of a knowledge 
of the science and art of surgery. 

Ligation of the Principal Blood-vessels Nourishing- the Tumor. 
— It has been stated in the section on the Etiology of Tumors that 
a tumor can grow only if it receives an adequate quantitative and 
qualitative blood-supply. Sudden or progressive anemia of a tumor 
determines degeneration of the tumor-tissue. Surgeons have made a 
practical application of this knowledge, and have resorted to meas- 
ures calculated to deprive the tumor of the necessary blood-supply 
by ligating the principal arteries nourishing the tumor. This method 
of treatment was first introduced in 165 1 by Harvey. It has been 
most frequently resorted to in the treatment of tumors of the thyroid 
gland. 

Wolfler has recently revived and improved the operation. It has 
been shown that ligation of the superior and inferior thyroid arteries 
on both sides has a curative effect in the treatment of non-malignant 
tumors of the thyroid gland. 

In inoperable cases of malignant tumors of the pharynx and the 
upper part of the neck the primitive carotid artery has been tied 
repeatedly without even temporary benefit. 

Ligation of the uterine arteries has recently been proposed as a 
conservative operation in the treatment of bleeding fibroids of the 
uterus. The results so far obtained are not conclusive as to the merits 
of the operation. It is possible that in the future benign tumors of 
other organs will be treated successfully upon the same principles. 
Ligation of the principal arteries nourishing a tumor is occasionally 
resorted to advantageously as an operation preliminary to a subsequent 
extirpation. 

Galvano-puncture. — Electricity was used in the treatment of tu- 
mors by De Haen. Galvanism came next in use. In a case of a large 
sarcoma of the neck in which Likke resorted to galvanism the tumors 
appeared to become smaller and more movable under its use, but care- 
ful observation showed that the reduction in size and the temporary 



TREATMENT OF TUMORS. 1 17 

improvement followed the subsidence of an accompanying inflamma- 
tion, and that the treatment had no effect whatever on the tumor. 
This has been the uniform experience of surgeons in the external 
application of electricity in the treatment of tumors. Electro-puncture 
and galvano-puncture have found special application in the treatment 
of cystic tumors. At the International Medical Congress held in 
Philadelphia in 1876, Semeleder of Mexico read a paper on. this sub- 
ject, from which it appeared that electricity was destined to supplement 
the knife in the treatment of ovarian cysts. Apostoli made similar 
claims for this agent in the treatment of myofibroma of the uterus at 
the International Congress held in the city of Washington. It is now 
generally conceded that electro-puncture and galvano-puncture occa- 
sionally bring about improvement, but the results have not been 
such as to entitle this therapeutic resource to be included among the 
radical measures in the treatment of tumors. The application of the 
electrolytic action of the galvanic current was first made use of by 
Nelaton. As the electrolytic action is attended by gas-formation, Bill- 
roth did not resort to electrolysis in the treatment of vascular tumors, 
as he feared that the gas evolved might enter the blood-vessels and 
produce dangerous if not fatal gas-embolism. Electrolysis has a lim- 
ited sphere of application in the treatment of superficial nasvi. 

Parenchymatous Injections. — Injections of solutions of perchlo- 
ride of iron have had an extensive application in the treatment of 
vascular tumors. The use of coagulating substances as injections into 
a vascular tumor is attended by great risks, and should entirely be 
abandoned. Fatal embolism has attended this procedure by the separa- 
tion of a fragment of the blood-clot, with the result of causing sudden 
death. In other instances the injection was followed by suppuration, 
thrombo-phlebitis, and pyemia. Thiersch injected into carcinomatous 
growths a solution of nitrate of silver, with the object of bringing 
about speedy degenerative changes. This treatment proved a com- 
plete failure. Broadbent used for the same purpose dilute acetic acid, 
with similar negative results. Carbolic acid and other antiseptic sub- 
stances have been used in the treatment of malignant tumors, but none 
of them have answered the expectations of those surgeons who regard 
with favor the microbic origin of malignant tumors. The use of ani- 
line dyes, introduced by Mosetig von Moorhof, has had an extended 
trial, but so far no positive results have been realized. The employ- 
ment of parenchymatous injections in the treatment of inoperable 
tumors should be encouraged, as it is within the range of possibility 
that there may be found a substance which, when brought in con- 
tact with the tumor-tissue, may prove beneficial either by its destructive 



Ii8 PATHOLOGY AND TREATMENT OF TUMORS. 

effects on the new cells or by effecting a change in the type of tissue- 
proliferation. 

Injection of Erysipelas Toxines. — It has been known for a long 
time that an intercurrent attack of erysipelas frequently retarded the 
growth of a sarcoma, and in exceptional cases resulted in a permanent 
cure. Billroth and others have reported such cases. Since the dis- 
covery of the microbe of erysipelas by Fehleisen patients suffering 
from inoperable malignant tumors have been inoculated with pure 
cultures of the streptococcus of erysipelas. Some of the cases sub- 
jected to this treatment improved, others received no benefit, and in 
some the symptoms were aggravated and the treatment hastened the 
fatal termination. Coley and Bull have recently made use of sterilized 
cultures of the erysipelas microbe, and have obtained equally good, 
if not better, results than were obtained with the active cultures. This 
treatment is certainly preferable to the employment of active cultures, 
as it is not attended by the risks incident to an attack of erysipelas. 
These authors have found that the employment of the sterilized cult- 
ures was followed by better results in the treatment of sarcoma than 
in that of carcinoma. It has also been ascertained that the culture 
made of the streptococcus of erysipelas and the bacillus prodigiosus 
is more effective than the culture of the streptococcus alone. As in 
the case of Koch's lymph, the injections are followed by a rise in the 
temperature. The diluted sterilized culture as sold in the shops is used 
in doses of from 5 to 30 minims. The treatment should be commenced 
by injecting 5 minims every alternate day, increasing the dose gradu- 
ally. Koch's syringe (Fig. 45) should be employed for this purpose. 
The writer has given this treatment a fair trial in twelve cases, but so 
far no permanent beneficial results have been obtained. 




Fig. 45. — Koch syringe. 

Cauterization. — The destruction of tumors by caustics and by the 
actual cautery is one of the most ancient resources of the surgeon in 
the bloodless removal of tumors. The actual cautery was preferred 
by the surgeons of ancient times, because it not only destroyed the 
tumor quickly, but at the same time also acted as a hemostatic. The 
use of the actual cautery has had an extended application also as a 
supplement to the knife in effecting the destruction of remnants of 
tumor-tissue and in arresting hemorrhage. The actual cautery is occa- 



TREATMENT OF TUMORS. 



nc 



sionally used now in the removal of small surface carcinomata it 
patients who show an unconquerable objection to the use of the knife 
and in the palliative treatment of inoperable ulcerating malignan 
tumors. The instrument employed almost universally for this purpos< 
is Pacquelin's cautery (Fig. 46). The bulb- or knife-point is used mos' 
frequently in the treatment of malignant tumors, while the needle-poin' 
is used almost exclusively in the treatment of angiomatous tumors 
The employment of the potential cautery— chemical caustics in differ- 
ent forms — has found a more varied and extended application than tha; 
of the actual cautery. It is to be regretted that this method of treat- 
ment has fallen almost entirely into the hands of charlatans. The 
ignoramus fears blood ; the public always has had, and always wil 
have, faith in bloodless procedures ; hence the great popularity whicr 
chemical caustics have en- 
joyed in the treatment of 
tumors. The war between 
caustics and the knife has 
been a long and bitter one, 
and it is by no means ended. 
The cause of caustics is de- 
fended by a great army of ig- 
norant, irresponsible, money- 
loving quacks, supported 
and cheered by an admiring 
misled public. On the side 
of the knife stands the hon- 
est surgeon who holds out 
only guarded promises, confronted by patients suspicious of his skil 
and in great dread of a bloody operation. The ultimate victory of the 
knife must rest on earlier and more thorough operations. The quack 
has been educating the people to the effect that the caustic he uses de- 
stroys only cancer-tissue, and he takes special pains to point out to his 
patient that the remedy has not only succeeded in removing the cancer 
but has also followed its roots. The patient, with the specimen care- 
fully preserved in alcohol, returns to his home happy and hopeful, anc 
exhibits the specimen cancer, roots and all, with satisfaction and a cer- 
tain feeling of pride as a signal triumph of quackeiy over regulai 
medicine. In the face of such a state of things it is no wonder thai 
the surgeon who has regard for his own reputation is slow in substi- 
tuting caustics for the knife. Chemical caustics have had an exten- 
sive trial at the hands of the regular profession. Their merits anc 
disadvantages have been studied by competent and honest surgeons. 




Fig. 46. — Pacquelin cautery. 



120 PATHOLOGY AND TREATMENT OF TUMORS. 

They occupy at the present time a limited and special field in the 
treatment of tumors. 

The value of different caustics depends on the manner of their 
action : the more potent its action, the less the liability to hemorrhage ; 
the less the pain it inflicts, the more useful it is. The treatment of 
small benign tumors by the application of caustics often results in a 
permanent cure. In the treatment of carcinoma this is seldom the 
case. The difficulty encountered in this method of treatment is that 
one application is seldom sufficient to destroy all the tumor-tissue, 
and that repeated applications cause so much suffering and distress 
that few patients will endure them long enough to effect a radical cure. 
Some of the caustics which have been used may become absorbed in 
amount sufficient to produce poisoning, and on this account should 
never be used : this is the case with arsenical preparations. When fluid 
caustics are employed the surrounding tissues should be protected 
carefully against their action. If the caustic is to be repeated, the 
second application is postponed until the eschar has separated. Pain 
is to be subdued by the application of cold and by hypodermic injec- 
tions of morphine. In the selection of the caustic we must be guided 
by the depth to which it is desirable to penetrate, as well as by the 
location to which liquid caustics are adapted. 

Caustic Potash. — Caustic potash is a very energetic caustic. The 
rapid liquefaction which it undergoes when applied to the tissues 
detracts somewhat from its advantages, and it must be watched care- 
fully and the tissues beyond its desired range of action must be pro- 
tected thoroughly. It cannot be employed safely in the treatment of 
tumors located in cavities. Its hemostatic action is not reliable. This 
substance is often mixed with caustic lime, the mixture constituting 
the famous Vienna paste, which is not much inferior to the caustic 
potash as a caustic. 

Chloride of Zinc. — This article, in the form of a paste known as 
Canquoin's paste, has been used quite extensively as a caustic. To 
increase its action in paste form it is necessary that it should receive 
a certain amount of moisture, and it must therefore be applied under 
the skin. If the skin over the tumor is intact, it should be made per- 
meable to the caustic by macerating it for some time with a dilute 
solution of caustic potash or by making multiple superficial incisions. 
It is a reliable hemostatic, which fact is an additional recommendation 
for its employment in the removal of vascular tumors. The eschar it 
produces is very dry and corresponds in size to the cubic volume of the 
mass of paste inserted. In a few days the eschar can readily be re- 
moved with the knife, when the cauterization is repeated. The caustic 



TREATMENT OF TUMORS. 



121 



arrows of Maisonneuve are composed of a paste of flour and chloride 
of zinc in the proportion of 3:1. Landolfi, a famous Italian cancer- 
doctor, used a mixture of chloride of zinc, chloride of gold, and chlo- 
ride of bromium. 

Arsenic. — The arsenical preparations, especially the paste of Frere 
Come, were popular for a long time, and proved useful in the removal of 
small epiblastic carcinomata about the face and the lip. Arsenic is an 
energetic caustic, but its action is slow. Intoxication from the absorp- 
tion of arsenic has repeatedly been observed. For some time arsenic 
was regarded as a specific in the treatment of carcinoma, but this delu- 
sion no longer prevails, as it has been found that its beneficial action 
when applied as a caustic depends entirely upon the depth to which 
tissue is destroyed, as is the case with all other caustics. 

Chromic Acid. — This acid inflicts less pain than any other liquid 
caustic, and has proved successful as a superficial caustic. It is used 
in the form of crystals or as a concentrated solution. 

Nitric Acid. — Of all the acids, nitric acid has been used most fre- 
quently as a caustic in the treatment of tumors. The eschar is of a 
yellowish color, and the resulting scar is small. Nitric acid is also 
a good hemostatic. 

Instead of resorting to cauterization from without, French surgeons 
devised a method by which caustics are inserted into the tissues of the 
tumor through punctures from different points, which method they 
termed " linear cauterization." The first attempts in this direction were 
made in 1700 by Deshaies Gendrou. His method consisted in intro- 
ducing pieces of caustic paste under the base of the tumor, with the 





Fig. 47. — Cauterisation en rayons (after Maison- 
neuve). 



Fig. 48. — Cauterisation en faisceaux {after Maison- 
neuve). 



expectation that the deep cauterization from different points would 
eventually separate the tumor from the tissues, when it would be cast 
off as a whole with the eschar. Under the name of " cauterisation 
en fleches " Maisonneuve in 1857 developed this procedure. He in- 



122 PATHOLOGY AND TREATMENT OF TUMORS. 

serted arrow-shaped pieces of chloride-of-zinc paste into the substance 
of the tumor after puncturing it at different points with a bistoury. 
He described three methods of procedure : First, the arrows are intro- 
duced on the same level in such a way that their points meet in the 
centre of the tumor (Fig. 47) ; second, the arrows are inserted from the 
surface like posts driven in the ground (Fig. 48) ; third, an arrow was 
inserted into the centre of the tumor, so that cauterization should pro- 
ceed from the centre toward the periphery — " cauterisation centrale " 

(Fig- 49)- 

In the removal of tumors of small size surface cauterization must 

be resorted to. If the tumor is large, Maisonneuve's procedures are 
preferable. They are, however, not devoid of danger. It has hap- 
pened in the practice of Maisonneuve that the caustic destroyed the 
walls of large blood-vessels, and upon the separation 
of the eschar troublesome and even fatal hemorrhage 
occurred. The writer recollects a case of carcinoma 
in the parotid region that was treated by a charlatan 
by caustics. Before the patient left the institution 
profuse hemorrhage occurred after separation of the 
last eschar. The patient was informed that the cure 
was completed, and was advised to return to his 
home. Soon after he left the institution there oc- 
Fig. 49 ^Ca^erisation curred another hemorrhage, which nearly proved fatal, 
centrale (after Maison- Greatly debilitated and almost exsanguinated, he was 
brought to the Presbyterian Hospital, Chicago. The 
dressings were saturated with blood. An anesthetic was administered, 
the dressings were removed, the neck was disinfected, and the common 
carotid artery was tied. Upon examination of the large surface partly 
covered by granulations and partly by fungous carcinoma-tissue, a 
large opening in the external carotid artery was found near the bifur- 
cation of the common carotid. The surface was disinfected and the 
opening in the vessel was tamponed with iodoform gauze. The hem- 
orrhage did not return, and the patient left the hospital in the course 
of a week. 

Immediate and complete removal of a tumor is accomplished by 
the employment of the ligature, the ecraseur, the galvano-caustic wire, 
and the knife. The complete removal of a tumor is effected in the 
safest manner and most expeditiously by the use of the knife, but, as 
all the procedures enumerated above are still endorsed by eminent 
surgeons, and as all of them are occasionally resorted to, they merit 
a brief description. 

Ligature. — The ligature is an ancient surgical resource in the treat- 




TREATMENT OF TUMORS. 



123 



ment of tumors. Ambrosius Pare and De Saliceto removed with it 
polypoid growths from the nasal cavities and from the cervix of the 
uterus. Mayor described this procedure, under the name of ligature 
cu masse, as a new discovery, improved the technique, and extended its 
use to different parts of the body. The ligature was used in two ways : 
1. It was tied so firmly that it strangulated all blood-vessels, producing 




Fig. 50. — Maisonneuve's constrictor. 



rapid necrosis of the tumor ; 2. It was tightened from time to time, in 
order to cut its way more slowly through the tissues. The single 
ligature was used in tying off pedunculated growths. Its use was ex- 
tended to the removal of tumors with a wide base, with the introduc- 
tion of the double and multiple ligatures. The ligatures were either 
tied on the surface of the skin or inserted with needles around and 
under the base of the tumor. Whenever pos- 
sible a pedicle was made artificially by making 
traction upon the tumor before inserting and 
tying the ligatures, or by dissecting off the skin 
around the base of the tumor. The percutane- 
ous ligature has been employed extensively in 
the treatment of angioma. Recently absorb- 
able ligatures of catgut and kangaroo tendon 
have been substituted for the silk and metallic 
ligatures in the subcutaneous ligation of vas- 
cular growths. Various instruments have been 
devised for the progressive constriction of the 
base of the tumor by the ligature. Maison- 
neuve's (Fig. 50) is constructed upon the same 
plan as Chassaignac's ecraseur. In Koderik's fig. 51. 
instrument (Fig. 51) the ligature is tightened at 
intervals over a row of perforated shot. Manec contributed largely 
toward the perfection of the technique of the subcutaneous ligature. 
He devised a needle for this special purpose, the manner of use of 
which is well shown in Figure 52. Fergusson's method (Fig. 53) 
is simpler and does not require a needle of special construction. The 
great objections to the use of the ligature are the pain it causes 
and the liability to infection that attends its use. 




Koderik's rosary instru- 
ment. 



The ligature is used 



124 



PATHOLOGY AND TREATMENT OF TUMORS. 



at the present time only in exceptional cases of angioma. The aseptic 
ligature should be used, attended by all necessary antiseptic precautions. 




Fig. 52. — Manec's method of percutaneous ligation of a tumor (after Manec). 

Galvano-caustic Wire. — Recognizing the disadvantages of the silk 
and metallic ligatures in the removal of tumors, Middeldorpf in 1852 





Fig. 53, — Fcrgusson's percutaneous ligature (after Fergusson). 

substituted for ligation the galvano-caustic wire. Like the ligature, it 
has been used in severing the tumor from the body by cutting its way 



TREATMENT OF TUMORS. 



125 



from the surface and by destroying the tumor-tissue subcutaneously. 
The latter method of application has proved very useful in the treat- 
ment of subcutaneous angioma, as the overlying skin is protected 
against cauterization by insulating the platinum wire at the points of 
entrance and exit. The galvano-caustic wire has been a great improve- 
ment over the ligature, as it completes its work almost as quickly as 
the knife and leaves a wound much less liable to infection. One great 
objection to the use of the galvano-cautery is the well-known fact that 
the apparatus is very liable to get out of order, often necessitating a 
resort to other measures. With few exceptions it has been superseded 
by the needle-point of the Pacquelin cautery. 

Bcrasement Lineaire. — The removal of tumors by linear crushing 
was devised by Chassaignac. The parts included in the chain or wire 
of the ecraseur are divided slowly and, if no large vessels are present, 
bloodlessly. Chassaignac was an enthusiast in the use of his ecraseur 




Fig. 54. — Chassaignac's chain ecraseur. 



(Fig. 54). In his practice it almost displaced the knife. According to 
Chassaignac's own directions, the tissues should be divided very slowly, 



o- 




Fig. 55. — Wire ecraseur. 



for the purpose of guarding more efficiently against hemorrhage. That 
hemorrhage is not always prevented even by exercising the greatest 
caution is well known. The writer has seen profuse hemorrhage from 
both lingual arteries after amputation of the tongue by the ecraseur. 
Rhinologists and laryngologists have invented minute ecraseurs upon 
which they rely almost exclusively in the removal of polypoid growths 
from the nasal cavities and the larynx. The general surgeon at the 
present time seldom resorts to the ecraseur. Mr. Hutchinson prefers 



126 PATHOLOGY AND TREATMENT OF TUMORS. 

it to the knife or the scissors in removing the tongue, but few surgeons 
could be induced to follow his example. 

Avulsion. — The removal of a pedunculated tumor by torsion is 
accomplished by grasping the pedicle, as close to its attachment as pos- 
sible, with a pair of strong forceps and twisting it around its axis until 
the tumor is torn from its bed. This has been a favorite method of 
removing polypoid growths of the nose and the uterus. If the tumor 
is soft, the removal is often incomplete, and a return of the growth is 
the rule ; if the pedicle is large and firm, unnecessary damage is often 
inflicted upon the organ to which the tumor is attached. Avulsion 
should give way to the galvano-caustic wire, to the ecraseur, or to 
enucleation. 

Extirpation. — The general surgeon, with few exceptions, removes 
all tumors by extirpation. This method of eradicating tumors has 
precision. The knife can be made to include any tissue that may pre- 
sent a suspicious appearance, and it enables the surgeon to examine 
the tissues as he proceeds with the operation, and thus to outline more 
accurately the limits of the tumor. The operation can be performed 
painlessly by placing the patient under the influence of an anesthetic, 
and the wound can be made to heal by primary intention. The con- 
trast between the speedy and painless removal of a tumor by excision 
and the slow and painful destruction by caustics is great. The wound 
left after the use of caustics has to heal by a slow process of granula- 
tion, and, as so often happens, incomplete removal transforms a subcu- 
taneous into an open ulcerating cancer, with all the risks and incon- 
veniences incident to such a condition. Incomplete removal by caustics 
invariably results in aggravation of all the local conditions, as the 
inflammation which follows cauterization imparts a new stimulus to 
tumor-growth. The risks of hemorrhage and infection are much greater 
after cauterization than after excision. The removal of benign tumors, 
carcinoma, and sarcoma by extirpation should be made the rule, and 
the use of caustics be reserved for exceptional cases of carcinoma. 

The idea that the results after extirpation of malignant tumors are 
better if the wound suppurates and heals by granulation is wrong both 
in theory and in practice. Inflammation is one of the most influential 
factors in effecting a speedy recurrence if the tumor has not been 
removed completely. In extirpation of tumors it should be the aim of 
the surgeon to secure healing of the -wound by primary intention. If the 
margins of the wound cannot be brought into apposition by suturing, 
owing to the removal of an extensive area of skin with the tumor, the 
margins should be approximated as far as possible by tension-sutures, 
and the remaining surface be covered with a Wolfe skin-graft or with 



TREATMENT OF TUMORS. 127 

a mosaic of Thiersch skin-grafts. For the purpose of preventing wound- 
complications, and with the view of securing speedy healing of the wound 
and of obtaining an ideal functional and cosmetic result, it is absolutely 
necessary to resort to the strictest antiseptic precautions in the extirpation 
of a tumor, irrespective of its size or its location. 

The instruments should be sterilized by boiling for at least ten 
minutes in a 1 per cent, solution of carbonate of soda. Sterile liga- 
tures, sutures, and gauze sponges should be used. The field of opera- 
tion and the hands of the operator and of his assistants should be 
disinfected thoroughly by scrubbing with warm water and potash soap 
for at least five minutes, followed by washing in a 1 : 1000 solution of 
corrosive sublimate. If the tumor occupies any of the large cavities, the 
patient must be prepared thoroughly for the operation by preliminary 
treatment continued for several days. The external incision should be 
amply large, to facilitate deep dissection. The danger of a wound is 
no longer estimated by its size. The attempt to remove tumors 
through small incisions is attended by greater risks of injury to 
important structures than when the parts we wish to avoid are well 
exposed by a large incision. The incision should be made in a loca- 
tion and direction which will render the tumor most accessible and 
which will not implicate important structures. It must be remem- 
bered that tumors often displace important vessels and nerves, and on 
this account special care is necessary to avoid these structures when 
displaced. In operating upon the extremities the incision should be 
made parallel with muscles. In extirpating tumors of the neck an 
incision in the direction of the sterno-cleido-mastoid muscle is usually 
made. A transverse incision is preferred by some operators in the 
removal of tumors of the thyroid gland. Submaxillary growths should 
be approached through a slightly-curved incision below the border of 
the lower jaw. In amputations of the breast the incision is prolonged 
behind the border of the pectoralis major muscle to the apex of the 
axilla. Tumors of the groin are laid bare by making an incision 
parallel with and a little below Poupart's ligament, and joining it by 
a vertical incision over the femoral vessels extended to the apex of 
Scarpa's space. A slightly-curved incision affords more room than 
a straight one. If the skin or the mucous membrane over the tumor 
is implicated, it is included between two elliptical incisions and is 
removed with the tumor. After a benign tumor has been reached, 
cutting instruments are laid aside and the tumor is removed by enucle- 
ation, using for this purpose the finger, Kocher's director, or blunt- 
pointed scissors. Extirpation of osteoma and chondroma requires the 
use of the chisel or the saw. Some cysts have such firm attachments 



128 PATHOLOGY AND TREATMENT OF TUMORS. 

that enucleation is impracticable, in which event their removal is effected 
by careful dissection. If the extirpation of a tumor requires a prelim- 
inary myotomy, the muscle should be united by buried absorbable 
sutures before the external wound is closed. If a nerve or a tendon 
is accidentally or intentionally cut, it is united in a similar manner. 
If an important fascia has been divided, it is separately sutured. As 
benign growths are aseptic pathological conditions, the external wound 
can be closed throughout by sutures and sealed. The after-treatment 
should include rest of the part operated upon, which can be secured 
by rest in bed, bandages, splints, etc. Operations for carcinoma and 
sarcoma are attended by great difficulties, as with the tumors the sur- 
geon must include a zone of tissue surrounding them, and must usually 
extend the operation far into apparently healthy tissue to reach and 
remove the products of regional infection. Two great difficulties con- 
front the surgeon during the course of the operation. In the absence 
of any limiting structures he is often in doubt concerning the amount of 
tissue he should include with the tumor, and, again, to what extent he 
should invade the vicinity in his attempts to eradicate the disease. No 
definite rules can be laid down to guide the surgeon in deciding these 
most important points of the operation. He must take pathological 
anatomy as his guide. It is well known that sarcoma follows connec- 
tive tissue, blood-vessels, nerve-sheaths, and muscles. The surgeon 
must therefore include as much tissue in the direction of these pathways 
as is permissible with the importance of the structure involved. The 
amount of tissue to be included must necessarily vary with the character 
of the tumor, its location, and the importance of the structures in its 
vicinity. The farther the tumor is away from important vessels and 
nerves, and the more tissue can be included, the better will be the 
results. As a rough estimate the writer would say that the incisions 
should be made at least an inch away from the periphery of the tumor. 
Sarcoma of bone usually demands amputation, although recently suc- 
cessful local operations have been made in cases of circumscribed 
myeloid sarcoma. If amputation is performed, the entire bone should 
be removed ; that is, amputation should be made through or above the 
proximal joint. In the removal of a malignant tumor enucleation must 
never be attempted : the tumor must be excised. Extirpation here means 
the removal not only of the tumor, but also of all infected tissues in its 
vicinity or in the same region. The knife or the scissors must be used 
from the beginning to the end of the operation. The extirpation of a 
carcinoma, unless the tumor involves a free surface and is recent and 
localized, must be followed by excision of the lymphatic glands of the 
same region, whether enlarged or not enlarged. The tumor and the string 



TREATMENT OF TUMORS. 129 

of lymphatic glands should be removed in one continuous piece by 
thorough and clean excision. It lias been shozvn that carcinoma fre- 
quently selects the connective tissue as pathways for local infection ; hence 
as much of the connective tissue as possible in the vicinity of the tumor 
should be included in the excision. Muscles are often divided or removed 
in operations for malignant tumors. Partial removal for malignant dis- 
ease of organs not essential to life is bad surgery. In operating for 
malignant disease parts and tissues must be removed regardless of the 
cosmetic result. The surgeon who operates with a view of securing a 
good cosmetic result is very liable to perform an incomplete operation. 
The primary indication in the extirpation of a malignant tumor is to re- 
move all infected tissues ; the cosmetic result is of secondary consideration, 
and can be improved immediately or later by plastic operation. After 
operation it is advisable to watch the patient carefully, and in case of 
recurrence to repeat the operation. By following this course there is 
no doubt that the patient is made more comfortable and life is pro- 
longed, and occasionally a radical cure is effected by repeated opera- 
tions for local recurrence. 

Contraindications to radical operations for malignant disease are — 
1. Metastasis; 2. Extreme old age; 3. Regional infection beyond the 
reach of complete removal of diseased tissue without imminent danger 
to life ; 4. Very extensive local infection, as in cases of diffuse cancer 
en cuirasse. 

Palliative Treatment. 

Palliative treatment is indicated in cases of inoperable malignant 
tumors. It consists in protecting the tumor against irritation, and, in 
open ulcerating tumors, in partial removal, antiseptic applications, and 
the use of anodynes to subdue pain. If the tumor is on the surface, 
it should be protected against friction by the clothing by a compress 
of aseptic absorbent cotton held in place by a bandage or by strips of 
adhesive plaster. As soon as indications of ulceration appear, the sur- 
face should be disinfected thoroughly and be protected by an antiseptic 
dressing, so that when the tumor-tissue is exposed the ulcerated sur- 
face will be protected against infection. If the ulcer or fungous mass 
has become infected, it is necessary to correct the fetor by the employ- 
ment of strong antiseptic applications. Chlorine-water, solution of per- 
manganate of potash, saturated solution of acetate of aluminum, and 
solution of chlorinated soda (Labarraque's solution) are most efficient 
in correcting the putrefactive processes. A 10 per cent, solution of 
chloride of zinc, carefully applied with a camel's-hair brush to the dried 
surface of the ulcer, is one of the best disinfectants. The writer has 
9 



130 PATHOLOGY AND TREATMENT OF TUMORS. 

found a solution of hydrate of chloral (2 : 100) not only a good anti- 
septic, but also a local anodyne. The stronger antiseptics, creosote, 
carbolic acid, and corrosive sublimate, must be used with caution, as 
the prolonged use of even a weak solution might result in intoxication. 
Vegetable charcoal has been popular for a long time as a deodorizer. 
Great benefit often follows the removal of fungous granulations with 
a sharp spoon, followed by an energetic use of the actual cautery. 
This treatment is frequently resorted to with decided temporary im- 
provement, so far as the local conditions are concerned, in the palliative 
treatment of inoperable carcinoma of the uterus. Bleeding from the 
ulcerated surface, commonly of capillary origin, is best controlled by 
applying a few layers of gauze saturated with liquor, ferri sesqui- 
chlorati, over which an antiseptic tampon is applied, and the whole kept 
in place with the dressing applied to the ulcer by broad strips of ad- 
hesive plaster. If a large vessel is the source of hemorrhage, and can 
be tied neither in loco nor at a distance, the antiseptic tampon will have 
to be relied upon. Very little is to be expected in the way of allevi- 
ating pain from local anodynes ; of these, cocaine has proved the most 
useful. A strong solution (10 per cent.) of cocaine applied to ulcerating 
carcinomata of the cavity of the mouth has done much to relieve pain 
and dysphagia. Arnott derived great benefit from cold applications. 
The cold coil or the ice-bag deserves a trial as a local anesthetic. Sub- 
cutaneous injections of morphia have to be relied upon to allay pain 
and to procure sleep. The smallest dose possible should be com- 
menced with ; the dose must be increased rapidly as the pain increases 
in severity and the patient becomes habituated to the use of the drug. 



XII. CLASSIFICATION OF TUMORS. 

A rational, systematic classification of tumors is to the surgeon 
what the analytical key is to the botanist. A uniform system of classi- 
fication of tumors is one of the great wants of modern pathology, and 
all attempts in this direction have proved failures. New classifications 
are being introduced from time to time, but each of them invariably 
represents the individual author's own views regarding the origin and 
nature of tumors. A classification which will be intelligible to the 
student and of practical utility to the surgeon must be based on the 
histogenesis and the clinical aspects of tumors. As the histologist 
traces the normal tissue to its embryonic origin, so the pathologist must 
follow the tumor-cells to the embryonic matrix which produced them, 
in order to trace tumors to their primary histogenetic origin and to 
classify them upon a histological basis. The botanist includes in the 
same class wholesome and poisonous plants from their morphological 
resemblance, and the pathologist groups together tumors which have 
a common embryonic origin ; but in making a classification he must 
make a subdivision according to their clinical aspects, which means 
their relation to the surrounding tissues and the organism. To Virchow 
belongs the honor of having attempted the first systematic classifica- 
tion of tumors on a histological basis. 

Virchow's Classification*. 

i. Histioid ; 

2. Organoid ; 

3. Granulomata ; 

4. Teratoid ; 

5. Combination tumors ; 

6. Extravasation- and exudation-tumors ; 

7. Retention-cysts. 

Among the histioid tumors he included all tumors composed of one 
kind of cells. 

The class of organoid tumors he made to include all tumors com- 
posed of several kinds of tissue-elements with a definite typical arrange- 
ment of the component parts. 

131 



132 PATHOLOGY AND TREATMENT OF TUMORS. 

Among the infective swellings he included carcinoma and sarcoma, 
calling this group " granulomata." "Teratoma" was the term applied 
to tumors composed of a system of organs arranged in an imperfect 
manner, of course, and representing different parts of the body, and 
sometimes a perfect body, such as dermoid cysts and foetus in fcctu. 

" Combination tumors," as the term implies, are tumors composed 
of different kinds of tumor-tissue representing two or more histioid 
tumors, such as adeno-chondroma, myofibroma, etc. 

The extravasation- and exudation-tumors include swellings con- 
taining blood, serum, or inflammatory products. 

A pure histioid tumor, according to Klebs, could be found only in 
a very small epithelioma and a small sarcoma. In large tumors it is 
represented by angioma. 

The term "organoid " as applied to tumors is incorrect and mislead- 
ing, because even the most perfectly-developed adenoma, as well as all 
the rest of the tumors, lacks physiological function. 

Compound tumors occur in consequence of degenerative changes 
or of change in the type of tissue-growth in a primary simple tumor. 

The granulomata and the extravasation- and exudation-swellings, 
which should no longer be classified with tumors, will be eliminated 
from our classification. 

Retention-cysts are not tumors, but have so much in common with 
tumors, and occupy such a conspicuous place in the differential diag- 
nosis, and require so frequently the same treatment as tumors, that 
they will be treated under a separate head in this book. 

Cohnheim's Classification. 
Fibroma ; 
Lipoma ; 
Myxoma ; 
Chondroma ; 
I. Connective-tissue type. { Osteoma; 

Angioma ; 
Lymphangioma ; 
Lymphoma ; 
Sarcoma. 
Epithelioma ; 
Onychoma; 
Struma ; 
Cystoma ; 
Adenoma ; 
Carcinoma. 



Epithelial type. 



CLASSIFICATION OF TUMORS. 



J 33 



3. Myomata. 



f Myoma laevi-cellulare ; 
I Myoma stri-cellulare. 
Neuroma ; 



Archiblastic neoplasms. 



4. Neuromata. I 

V Glioma (Klebs). 

5. Teratomata. \ (Virchow). 

The classification of tumors as prepared by a committee of the 
College of Physicians and Surgeons of London is very defective, as 
among tumors it includes swellings the product of other pathological 
conditions. 

Williams's Classification. 

1 . Lowly organized : 
( Squamous ; 

Epithelioma. I Cylindrical ; 
I Glandular. 

2. Highly organized : 
Adenoma ; 

Cystoma (neoplastic) ; 
Papilloma. 

1 . Lowly organized : 
Sarcoma ; 
Myxoma. 

2. Highly organized : 
Fibroma ; 
Lipoma ; 
Chondroma ; 
Osteoma. 

Williams and Klebs classify tumors into archiblastic and parablastic, 
in accordance with the division by His of tissue in the embryo. For 
the sake of simplifying the location of tumors anatomically in the diag- 
nosis, as well as in pointing out the differences of structure and func- 
tion of the cells of the epiblast and hypoblast, we shall retain the 
distinction between epiblastic and hypoblastic tumors. 

Virchow from a practical standpoint divided all tumors again into — 
1. Homologous ; 2. Heterologous — terms which have been used wrongly 
as synonymous with the designation " benign " and " malignant." All 
malignant tumors are heterologous, but not all heterologous tumors arc 
malignant. According to Virchow, a heterologous growth is a tumor 
which in its histological structure deviates from the type of tissue from 
which it grows, while a homologous tumor is one which reproduces 
the type of tissue of the part or organ in which the tumor is located. 
The innocent tumors histologically very closely resemble normal tissue ; 



2. Parablastic neoplasms. 



134 PATHOLOGY AND TREATMENT OF TUMORS. 

no such resemblance can be seen in the malignant tumors. The former 
are homologous, the latter heterologous ; but there are instances where 
an innocent tumor is heterologous (chondroma), and malignant tumors 
present a homologous appearance during the earliest stages of their 
development. A familiar illustration of what is meant by the term 
" homologous " is furnished by a myofibroma of the uterus, because it 
contains all the tissue-elements of that part of the uterine wall with 
which it is in contact. A chondroma in any of the glands — as the paro- 
tid, mammary, and testicle — represents a benign heterologous tumor, 
because cartilage is not a normal histological constituent of these 
glands. According to Cohnheim, all chondromata are heterologous 
tumors, as they never spring from cartilage where it normally exists, 
but occur in bone and soft tissues where cartilage has no legitimate 
physiological existence. Using the term " heterologous " in a strictly 
practical sense, the only tumors that are destructive are those which 
are heterologous in their origin and location. The homologous tumors 
may become destructive only by accident. Heterotopic tumors are 
heterologous tumors. " Heteroplasty " is another term introduced by 
Virchow, and in its strictest sense it takes in the malignant tumors. 
According to the views of this author as to the origin of malignant 
tumors, in cases of sarcoma and carcinoma during the earliest stages 
we meet with indifferent cells which, according to the nature of the 
initiative, assume an epithelial or connective-tissue type. It must be 
remembered that Virchow entertained the belief that carcinoma and 
sarcoma have a common origin in connective tissue, and that during 
a later stage the new products differ as their cellular elements reach 
various degrees of development. 

Robin and Waldeyer showed conclusively that epithelial tumors are 
never developed from a connective-tissue matrix. Lancereaux, Klebs, 
and others have excluded from the mesoblastic tumors endothelioma, 
as being a separate type closely resembling epiblastic and hypoblastic 
tumors. Lancereaux described endothelial tumors of the lymphatics 
of the peritoneum ; Robin, of the arachnoid and peritoneum ; Gaucher, 
of the spleen from the endothelia of blood-vessels and lymphatic 
glands ; Monod and Arthraud, of the retina from the vascular endo- 
thelia. 

Sutton claims that the same relation exists between sarcoma and 
endothelioma as between carcinoma and epithelioma. We shall include 
endothelioma among the malignant mesoblastic tumors, and thus 
adhere strictly to the classification made in accordance with the division 
of embryonic tissue into the three germinal layers. We shall also 
endeavor to show that the endothelial cells are capable of being trans- 



CLASSIFICATION OF TUMORS. 135 

formed into ordinary connective tissue, and vice versa, and that their 
close histological and pathological relationship to the connective-tissue 
tumors would, a priori, tend to prove that they are subject to tumor- 
formation of the same type as the common connective tissue of similar 
histogenetic origin. From a practical standpoint, the division of tumors 
according to their clinical aspects manifested by their relations to the 
adjacent tissues and to the organism has always been, and always will 
be, of the greatest importance to the surgeon. Clinically, tumors have 
been divided into — 1. Benign; 2. Malignant; 3. Suspicious. We have 
explained elsewhere why the third class should be abolished. A tumor 
is cither benign or malignant. The tumors classified heretofore as sus- 
picious are tumors which from their structure or location present con- 
ditions not favorable for thorough removal by the usual operations 
made for the removal of benign tumors. Such tumors as chondroma 
and myxoma, about which there has always lingered a suspicion as to 
their benign nature, from a practical standpoint have been regarded 
as innocent growths, and incomplete removal is responsible for many 
relapses after operation. The sudden change in the clinical behavior of 
tumors which have been pursuing a benign course for perhaps a long time 
is no evidence of a semi-malignant nature of the tumor, but is an evidence 
that a benign tumor has undergone transition into a malignant stage, or 
that the tumor ivas malignant from its incipiency, and has passed from 
a latent into an active condition. All the embryonic germinal layers 
furnish matrices for benign and for malignant tumors. The clinical type 
of the tumor depends upon the stage of arrest of development of the cells 
composing the matrix derived from the embryo or from embryonic cells 
of post-natal origin. 

The cells composing the tumor-matrix produce a tumor that is either 
benign or malignant. We shall speak of benign and malignant tumors 
of the epiblast and hypoblast and the mesoblast. A benign tumor is 
one which never extends beyond the germinal layer in which it had its 
origin, while a malignant tumor extends to and involves tissues derived 
from germinal layers other than the one from which it had its origin. 
The extension of a tumor to adjacent tissues irrespective of their structure 
or their embryonic origin has been regarded for a long tunc as the most 
reliable clinical proof of the malignant nature of the tumor. 

We shall classify tumors with special reference to their origin from 
the different germinal layers — the epiblast, the hypoblast, and the meso- 
blast — and to the stage of arrest of development of the cells composing 
the tumor-matrix. The lowly-organized tumor-tissue will represent the 
malignant tumors, and tumors composed of highly-organized cells will 
include all benign growths. In the description of the different varieties 



136 



PATHOLOGY AND TREATMENT OF TUMORS. 



tumors. 



of tumors the benign tumors will be considered first, as the tissues of 
which they are composed bear a closer resemblance to normal tissue 
than do the tissues of malignant tumors, and hence the deviation from 
the laws governing normal growth and nutrition is less marked. 

Author's Classification. 

( Papilloma; 

1. Epiblastic and hypoblastic J Adenoma; 

Cystoma ; 

Carcinoma. 

Fibroma ; 

Lipoma ; 

Myxoma ; 

Chondroma ; 

Osteoma ; 

Angioma ; 

Lymphangioma ; 

Lymphoma ; 

Laevi-cellulare ; 

Stri-cellulare ; 

■nt f Myelinic ; 

Neuroma, \ ' ' 

{ Amyelinic; 

(. Glioma (Klebs) ; 



2. Mesoblastic tumors. 



Myomata, 



Neuromata, 



Sarcoma. 

3. Epiblastic, hypoblastic, and \ -p f 

mesoblastic tumors. j 

4. Swellings caused by reten- ~) 

tion of physiological se- J- Retention-cysts, 
cretion. ) 



XIII. PAPILLOMA AND ONYCHOMA. 

Papilloma. 

A papilloma is a non-malignant epithelial tumor of the cutaneous or 
mucous surface. The essential part of the tumor is composed of epithe- 
lial cells ; the framework is furnished by the connective tissue under- 
neath the epithelial proliferation. The tumor-tissue proper is outside 
the limits of the vascular area, being separated from it by the mem- 
brana propria. The tissues of the epiblast and the hypoblast possess 
no independent organ-producing power, as their blood-supply is derived 
from the mesoblast. Epithelial cells in the normal mesoblast have no 
power to proliferate, hence in cases in which we find them multiply- 
ing here the mesoblast has undergone changes. The epithelial cells 
receive their nourishment from the blood-plasma and the leucocytes. 
As the stroma of an epithelial tumor is derived from the mesoblast, an 
epithelioma is a mixed tumor, in which, however, in accordance with the 
law of the legitimate succession of cells, the epithelial cells are derived 
from the epiblast or the hypoblast, and the connective tissue from the 
mesoblast. The development of new tissue from these sources is usu- 
ally unequal : sometimes the product of one, and sometimes that of the 
other, predominates. The unequal representation of the two different 
tissue-elements, epithelial cells and connective tissue, in this form of 
tumor has given rise to a great deal of confusion in classification. As 
papillary formations are found in many tumors not belonging to this 
variety, and as in many specimens fibrous tissue predominates, Virchow 
objected to papilloma as a separate variety of tumors. Rokitansky 
also treated papilloma as a variety of fibroma. Virchow proposed 
the name fibroma papillarc. However, in most tumors which deserve 
the designation " papilloma " the epithelial elements predominate and 
impart character to the tumor — the reticulum, if it predominates, being 
an accidental product. It is the intention of the writer to show, as far 
as possible, in connection with every variety of tumors, the counter- 
part in the normal tissues of the body. A papilloma of the skin under 
low power presents in a hypertrophic condition all the tissues of which 
the skin is composed. 

Histology and Pathology. — Papilloma of the skin, as shown in 
Figures 56 and 57, represents the same papillary structure as the skin, 

137 



138 



PATHOLOGY AND TREATMENT OF TUMORS. 



the number of papillae depending on the size of the tumor. In papil- 
loma of the hypoblast the villi correspond with the papillae of the 
epiblastic papilloma. The connective tissue and the vessels occupy 
the centre of the papillae (Fig. 57, a), and present, on vertical section 
of the tumor, finger-like projections conical in shape, the base corre- 
sponding with the base of the tumor, and the apex with the summit 
of each papilla. The epiblastic papilloma is covered by stratified layers 
of squamous epithelial cells. The new cells are produced near the 
vascular territory (Fig. 57, b). As the cells become older they lose the 
liquid part of their contents by exposure on the surface and by more 




Fig. 56. — Section of human skin (after Piersol) : a, stratum corneum ; b, stratum lucidum ; c, stratum 
granulosum ; d, stratum Malpighii ; e, /, papillary and reticular layers of corium ; g, stratum of adipose tis- 
sue ; /:, i, spiral and straight portions of duct of sweat-gland ; k, coiled portion of sweat-gland ; /, vascular 
loops occupying papillae of corium. 

distant removal from the vascular supply, forming the horny layer of the 
papilloma (Fig. 57, c). The papilloma of the hypoblast is composed of 
a connective-tissue stroma, usually softer and more vascular than that 
of epiblastic papilloma, and of cells corresponding in type to the cells 
of the mucous membrane in which the tumor is located. The pave- 
ments of cells which constitute the essential part of the tumor are made 
up of cylindrical cells. As hypoblastic tumors are constantly exposed 
to maceration by the contents of the hollow organs in which they are 
located, the epithelial cells become oedematous and are very liable to 
undergo myxomatous degeneration. Even by excluding the papillo- 



PAPILLOMA AND ONYCHOMA. 



J 39 



mata of inflammatory origin, we have, so far as the texture of the 
tumor is concerned, two varieties — (i) hard and (2) soft. The density 
of a papilloma depends on the amount and character of the stroma and 
the location of the tumor. If the stroma is abundant and compact, 




Fig. 57. — Papilloma of skin ; X 50 (Surgical Clinic, Rush Medical College, Chicago) : a, connective tissue; 
b, embryonic epithelial cells; c, old squamous epithelial cells. 

and if the tumor is not exposed to maceration by constant moisture, 
the tumor is firm ; on the contrary, if the stroma is scanty, if the con- 
nective-tissue fibres are loosely arranged and vascular, and if the 
epithelial cells, by constantly imbibing moisture from their environ- 
ment, become cedematous, the tumor is soft. The former conditions 
are most frequently presented by tumors of the skin and of mucous 
membranes derived from the epiblast, and the latter condition by tumors 
of mucous membranes lining hollow viscera and paved with columnar 
epithelium. In some instances a papilloma is covered by columnar 
epithelia if the tumor occupies a location surrounded by squamous 
epithelia. Hard papillomata are found most frequently in the skin and 
in the mucous membrane of the lip, mouth, soft palate, nose, larynx, 
urethra, vagina, and cervix uteri. The soft variety" is found most fre- 
quently in the mucous membrane of the intestinal canal and of the 
bladder. If a number of papillomatous tumors develop simultaneously 



140 PATHOLOGY AND TREATMENT OF TUMORS. 

or in succession in the same neighborhood, they form tumor-masses 
of greater or less circumference with a mushroom-like surface. The 
papillary excrescences are often branched, producing the so-called 
" dendritic vegetations." This condition is often found upon mucous 
surfaces. If the papilloma is not subjected to injury and is otherwise 
surrounded by favorable conditions for rapid growth, it often elongates 
into a delicate filamentous tumor, as is frequently seen in the bladder. 
The connective-tissue core conveys vessels and nerves to each papil- 
lary growth, the vessels forming loops as in the papillae of normal 
skin and in the villi of the intestinal mucous membrane. In papillary 
growths in joints the vessels are absent. In benign epithelial tumors 
of the skin we often find epithelial cells in concentric layers arranged 
in pearl-like masses, a proof of the independent proliferation of the 
epithelial cells. A papilloma never attains great size, large tumors of 
this kind being met with only as a result of the confluence of a number 
of tumors. By the aggregation of numerous tumors, masses the size 
of a fist are observed in the rectum and upon the prepuce and the labia 
majora. An individual tumor seldom exceeds the size of a cherry. The 
growth of a true papilloma is always very slow, papilloma manifesting 
in this respect much less activity than infective papillomatous growths. 
Among the degenerative processes which most frequently affect papil- 
lomatous tumors are cretefaction, myxomatous degeneration, and ulcer- 
ation. Cretefaction often arrests the further growth of a papilloma of 
the skin. Myxomatous degeneration most frequently attacks tumors 
of hypoblastic origin. Ulceration is the result either of mechanical 
irritation or of infection with pathogenic microbes through an abrasion 
or a fissure of the surface of the tumor. If in a pedunculated papil- 
loma the principal artery becomes thrombosed, either in consequence 
of an injury, such as twisting of the pedicle or traction, or as one of 
the results of an accidental inflammation, gangrene of the tumor is 
produced, usually resulting in a permanent cure. Psammoma is very 
prone to undergo calcification which limits tumor-growth — a fortunate 
occurrence, considering the importance of the locality occupied by such 
tumors. 

Transformation into Malignant Tumors. — Of all tumors, papillo- 
mata are most liable to undergo malignant transformation. The irrita- 
tion to which such tumors are frequently exposed by their location upon 
a surface will account satisfactorily for this well-established clinical fact. 
This transition is observed most frequently in tumors which occupy local- 
ities most exposed to irritation. We seldom hear of a papilloma of the 
cavity of the mouth undergoing such a transformation, while carcinoma 
frequently originates in a papilloma of the lip. Papilloma constitutes 



PAPILLOMA AND ONYCHOMA. 141 

a more frequent starting-point of a carcinoma than of a sarcoma. The 
deepest stratum of epithelial cells is composed of young cells which 
are in touch with the membrana propria, which, so long as the tumor 
remains benign, constitutes an impermeable partition between the essen- 
tial tumor-elements and its stroma, the subcutaneous or submucous 
connective tissue. If, in consequence of prolonged irritation or other 
exciting causes, this partition is damaged, the embryonic cells have 
access to the vascular part of the tumor, and, once there, the trans- 
formation from a papilloma into a carcinoma takes place. If, on the 
contrary, fetal " rests " or post-natal embryonic cells in the connective- 
tissue part of the tumor become environed by causes favoring tumor- 
growth, the papilloma is transformed into a sarcoma. Such a trans- 
formation was observed by Simon in a papillary growth of a joint. 
Sarcoma of the skin has occasionally a similar origin. 

Topography. — Papilloma is met with in various parts of the body, 
but some parts are more predisposed to it than others. It is most fre- 
quent in localities most exposed to irritation. We shall not include 
papilloma of an infective origin — as warts, condylomata, and molluscum 
contagiosum, all of which are inflammatory swellings and not true 
tumors — in the discussion of the topographical distribution of papil- 
loma. Warts (verruca) come and disappear mysteriously. They increase 
in size much more rapidly than papilloma, and they often disappear 
spontaneously. Condyloma, another papillomatous inflammatory swell- 
ing resembling in its structure papilloma, almost always appears mul- 
tiple in places where skin and mucous membrane meet and are bathed 
with infective discharges, usually of a gonorrheal origin. The vulva, 
the prepuce, and the anal region are the parts most frequently affected 
by condyloma. The removal of the primary causes usually results in 
a speedy cure. Molluscum (Bateman) or epithelioma contagiosum 
(Virchow) is now generally recognized as an inflammatory swelling. 
Its contagiousness is the best possible evidence that it is not a tumor. 
Haab succeeded in producing it artificially in animals by inoculation. 
Austrian and English dermatologists have traced its starting-point to 
sebaceous glands. The papillary growths of non-infective origin, the 
true benign epithelial tumors, do not disappear spontaneously ; their 
growth is limited by an inherent limitation of tissue-proliferation or by 
degenerative changes. These tumors have a very wide distribution, 
and the more important localities inhabited by them, and the different 
clinical varieties, will now be discussed. 

Skin. — Papilloma of the skin occurs in two principal forms: 1. 
Cornu cutaneum ; 2. Fibrous papilloma. In the former variety the 
tumor is composed almost exclusively of epiblastic tissue ; in the latter 



142 



PATHOLOGY AND TREATMENT OF TUMORS. 



the connective tissue derived from the mesoblast is present in varying 
proportions. 

Cor mi Cutaneum. — The cutaneous horn represents a form of pap- 
illoma in which the tumor is composed almost exclusively of desic- 
cated epithelial cells corresponding with the horny layer of the skin. 
The old cells, instead of becoming desquamated, remain attached to 
the tumor-matrix, forming projections varying in length from half an 
inch to twelve or more inches. Such horns are found most frequently 
on the scalp, temple, forehead, eyelid, nose, lip, cheek, shoulder, arm, 
elbow, thigh, leg, knee, toe, axilla, thorax, buttock, loin, penis (Fig. 58), 




Fig. 58. — Cornu cutaneum of penis (after Pick). 

and scrotum. The matrix of such tumors is very vascular. Horny 
tumors of the skin can readily be enucleated, and they seldom return 
after removal. A post-natal matrix for cutaneous horns is furnished 
most frequently by scars. Cruveilhier described a specimen of cornu 
cutaneum which originated from a scar following a burn of the forearm, 
the tumor reaching such an enormous size that amputation became 
necessary (Fig. 59). The tumors in this case were multiple. 

That desiccation is not the sole cause in the production and fixation 
of such an enormous mass of epithelial cells is shown by the fact that 
papillomata of a similar structure are occasionally found in dermoid 



PAPILLOMA AND ONYCHOMA. 143 

and sebaceous cysts. The matrix of a cutaneous horn undoubtedly 
not only possesses the inherent capacity of producing epithelial cells 
very rapidly, but also furnishes the cement-substance which fixes the 
old epithelial cells, thus preventing their removal by desquamation. 
There is no reason why papillomata should not develop as secondary 
formations in epithelial tumors of either a benign or a malignant type. 




Fig. 59. — Cornua cutanea from the scar of" a burn {after Cruveithier). 

Not infrequently we find in the interior of an adenoma, a cystoma, or a 
carcinoma papillary growths which resemble in every respect the surface 
papillomata, and which impart to the tumor additional pathological 
and clinical characteristics. Papillomatous cysts of the ovary (Fig. 60) 
are regarded with special interest by the surgeon. A semi-malignant 
nature was assigned to them long ago. There can be no doubt that 
in many instances such tumors are malignant from the beginning, 
but in other instances the papillomata are benign and remain so. The 
desquamated epithelial cells furnish here a part of the contents of the 



i44 



PATHOLOGY AND TREATMENT OF TUMORS. 



cysts (Fig. 60, d). As in surface tumors, the epithelial cells are strati- 
fied. Tumors of large size are formed by the aggregation and coales- 
cence of numerous smaller tumors. 

The fibrous papillomata of the skin occupy most frequently the region 






/I "sfm»m 



■ ■!'rU ■;■:-■■ ■■'■- ' ■ 



f?W 






■Sir; 



•«%* 



-,;-■.;?■ 



f? . *—~ y* t }-^j, 






9* 



» 



•"'"': 



A 






luJLf^ 



", /-^^4 




--«v.-fe 



Fig. 60. — Papillomatous cyst of ovary ; X no (Surgical Clinic, Rush Medical College, Chicago) : a, in- 
terpapillary space ; b, stroma ; c, epithelial lining ; d, amorphous, non-staining detritus with a few detached 
epithelial cells ; e, proliferating areas. 



of the face, scalp, and hands ; they are of slow growth and never 
attain large size. 

Respiratory Organs. — The larynx is the most frequent seat of papil- 
lomata. Morgagni's pockets are their favorite locations. They appear 
as isolated affections or as multiple tumors closely aggregated, giving 
to the mass a cauliflower-like appearance. The symptoms will vary ac- 
cording to the size and the location of the tumor. Hoarseness, cough 
harassing in character, and difficult breathing alternating with tempo- 
rary attacks of dyspnea, are some of the leading clinical features. Not 
infrequently, papilloma of the larynx undergoes transformation into car- 
cinoma, as was probably the case in the instance referred to in the sec- 
tion treating of the Transformation of Benign into Malignant Tumors. 

Digestive Tract. — The mucous membrane of the cavity of the mouth 
is derived from the epiblast and is frequently the seat of papilloma. 
The favorite localities are the mucous membrane of the cheek, the 
prolabium of the lip, the tongue, the soft palate, and the pharynx. The 
naso-pharyngeal space is frequently studded with papillomatous vegeta- 
tions. The stomach is almost exempt from this affection. The fre- 
quency with which the mucous membrane of the intestinal canal is 
affected increases in a downward direction. Papillomata are rare in the 
intestines, while in the rectum they are most frequent, and are either 



PAPILLOMA AND ONYCHOMA. 



145 




Fig. 61. — Papilloma of the rectum (after Liicke) : 
a, submucous connective tissue; /', papilla?, some 
of them branching, covered by columnar epithelia. 



sessile or pedunculated, constituting a frequent form of polypus of this 
organ. The writer has repeatedly seen the mucous membrane of the 
lower part of the rectum studded with papillary tumors varying in size 
from a hempseed to a cherry (Fig. 
61). The symptoms which attend this 
affection of the rectum are hemor- 
rhage, usually slight, tenesmus, and 
a glairy discharge. 

Urinary Organs. — The urinary 
tract is very often the seat of papil- 
loma, and no part of it is exempt. 
Papillomata are frequently located in 
the urethra, and especially around the 
margin of the meatus in the female. 
In this locality they are often multi- 
ple, and they are a source of great 
distress to the patient. The tumors 
are very vascular, are extremely sen- 
sitive to touch, and are the source of 
great pain during micturition. Papil- 
lomata of the male urethra are more 
frequent than was formerly supposed, and their presence can now be 
ascertained and their removal be facilitated by the use of the urethro- 
scope. They simulate, and have usually been mistaken for, stricture. 

Papilloma of the bladder is a frequent affection of this organ. The 
connective tissue is usually abundant and carries with it one or more 
vessels of considerable size. The main stem of the tumor usually gives 
off branches which in turn again become branched, giving to the tumor 
an arborescent structure (Fig. 62). As the connective-tissue core of the 
tumor is often covered by only one layer of epithelial cells, and the ulti- 
mate branches are often exceedingly delicate, it is easy to understand that 
such tumors frequently give rise to hemorrhage. If the principal artery 
of such a tumor is eroded or torn, the hemorrhage may become alarm- 
ing and even fatal. Sometimes small fragments of such a tumor are 
voided with the urine or are removed in the eye of the catheter, afford- 
ing the surgeon an opportunity to make a correct diagnosis, by the aid 
of the microscope, in what was before an obscure case. The cysto- 
scope renders valuable assistance in ascertaining not only the existence, 
but also the exact location and character, of the tumor. The liability 
of such growths to become transformed into malignant tumors is well 
known and generally recognized. A very interesting case of papil- 
lomatous tumors of the pelvis of the kidney is reported by Murchison 
10 



146 PATHOLOGY AND TREATMENT OF TUMORS. 

and quoted by Sutton (Fig. 63). The pelves of both kidneys were 
similarly affected, and the bladder contained two similar tumors, one on 
each side near the ureteral orifice. Sutton believes that in this case the 
tumors in the bladder were secondary, and were caused by the implan- 
tation of tumor-cells from the primary tumors upon the mucous mem- 
brane of the bladder. While this mode of origin is possible, it is more 
likely that the tumors developed from so many different tumor-matrices 
independently of one another. Multiple papilloma of the same surface 
or organ is not of rare occurrence. 




Fig. 62. — Papilloma of the bladder (after Perls). 

Female Organs of Generation. — The external genitals, the uterus, 
and all its appendages represent conditions favorable to the origin 
and development of papillomatous tumors. We shall, of course, ex- 
clude infective papillary swellings, which are of such frequent occur- 
rence upon the external genitals of gonorrheal patients and syphilitics. 
The labia (Figs. 64, 65) and the fringes of the hymen are frequently 
the starting-points of such growths. The tumors may be either single 



PAPILLOMA AND ONYCHOMA. 



147 



Artery, 




Fig. 63. — Pelvis of a kidney with a villous papilloma (after Sutton). 



Jt^i 




Fig. 64. — Papilloma of right greater labium (after Winckel): a, minor labium; l\ dilated meatus of the" 

urethra; c, papilloma. 



148 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 65. — Papillomata of lesser 
labium (after Winckel) : a, clitoris ; 
6, orifice of urethra ; c, papillomata ; 
d, fimbriated hymen. 



or multiple, sessile or pedunculated. In the absence of irritating dis- 
charges they occasion but little inconvenience, and they are usually 

accidentally discovered in examinations for 
other affections. 

The so-called " erosions " of the mucous 
membrane of the cervix uteri present under 
low power the typical structure of a papil- 
loma. Many of the small polypoid growths 
of the cervical canal are papillary tumors. 
The uterine mucous membrane is often the 
seat of multiple papillary tumors which may 
produce profuse menstruation and other 
symptoms simulating chronic endometritis or 
malignant disease (Fig. 66). Papilloma of 
the Fallopian tubes has been described by 
Hennig. 

Papillomata may develop upon the sur- 
face of the ovary, but more frequently from 
the wall of glandular cysts (Fig. 60). Papil- 
lary tumors upon the surface of the ovary 
have been observed by Gusserow, Klebs,-Birch-Hirschfeld, and Winckel. 
The intraglandular papilloma of the ovary will be described more fully 
in connection with proliferating papillary cysts of the ovary. 

Brain. — The brain is developed from the epiblast, but papillary 
tumors of this organ are exceedingly rare. The choroid plexuses are 
fringed with tufts of epithelium-covered villi which occasionally become 
the seat of papillary tumors. Douty describes a case of this kind in 
which the tumor attained the size of a bantam's egg. The patient was a 
boy seventeen years old, and the tumor produced focal symptoms which 
enabled the medical attendant to localize the tumor accurately during 
life. Sutton is of the opinion that psammoma is an epithelial tumor, 
but the majority of pathologists assign to it an endothelial origin, and 
it will be discussed more fully in connection with epiblastic tumors. 

Diagnosis. — The greatest difficulty encountered in the diagnosis of 
papilloma is to differentiate from it inflammatory papillary swellings 
and carcinoma. Inflammatory swellings usually grow rapidly and 
appear as a multiple affection. The microbic cause can often be ascer- 
tained. The swellings frequently present signs and symptoms of in- 
flammation which are lacking in papilloma. The difficulty would be 
greatly increased if a papilloma were at the same time in a condition 
of inflammation. Inflammatory papillary swellings may occur at any 
time of life, the only essential cause being the presence of pathogenic 



PAPILLOMA AND ONYCHOMA. 



149 



microbes in quantity sufficient to produce either a subacute or a chronic 
inflammatory process. Papilloma is most frequent in adults and in 
persons past middle life. Age is an important factor in the differential 
diagnosis between papilloma and carcinoma. Carcinoma affects most 
frequently persons past middle life. A papillary carcinoma almost with- 
out exception is indurated at its base — a condition absent in papilloma. 



•' 




Fig. 66. — Papillary excrescences of the mucous membrane of the cervix uteri, vertical section; X 22 
(after Karg and Schinorl). The papilla:, as well as the remnants of glandular tissue, are covered by cylin- 
drical epithelia. This section was taken some distance from a carcinoma, and two of the papilla at i are 
infiltrated with epithelial cells, indicating the beginning of carcinomatous degeneration. 



In doubtful cases the microscope will decide the diagnosis. The part 
of the tumor that it is most important to subject to microscopic ex- 
amination is the base. If sections from this part of the tumor show 
no epithelial cells on the vascular side of the membrana propria, the 
tumor is benign ; the presence of even a limited number of epithelial 
cells in the subcutaneous or submucous connective tissue is a positive 



150 PATHOLOGY AND TREATMENT OF TUMORS. 

evidence of malignancy. Papillomata of the meninges of the brain 
and of other inaccessible organs which produce no symptoms cannot, 
of course, be recognized during life ; if they produce symptoms, these 
must be studied carefully and be referred, if possible, to their proper 
source. Papillomata of the larynx, urethra, bladder, uterus, and rectum 
must be seen before they can be recognized, and for this purpose the 
different instruments that render them accessible to sight must be em- 
ployed. 

Prognosis. — Papillomata never attain a large size, consequently they 
only become a source of danger to life if, by causing compression of an 
important organ or by blocking an important passage, the function of 
an organ is impaired or abolished. A papillary tumor at the base of 
the brain may result in fatal cerebral compression. A papilloma of the 
larynx may be caught in the rima glottidis, and produce death from 
suffocation. Another element of danger is hemorrhage. A papilloma 
of the bladder has often been the source of serious and even fatal 
hemorrhage. The liability of a papilloma to undergo transformation 
into a malignant tumor must also be taken into consideration, and 
should be regarded as a forcible argument in favor of early operative 
treatment. 

Treatment. — The only treatment of a papilloma is a radical opera- 
tion. The tumors being usually small, they can be destroyed by the 
energetic use of the needle or the knife-point of the Pacquelin cautery, 
or be removed by excision. The cauterization or excision should in- 
clude the entire tumor-matrix ; if this is not done, a recurrence will 
almost surely follow the operation. Incomplete removal of a papilloma 
will also favor transformation of the balance of tumor-tissue into a 
malignant tumor. Laryngeal papillomata can be removed with a 
snare, aided by the use of the laryngoscope, or by laryngotomy. 
Laryngo-fissure is the preferable method if there is any question 
concerning the benign nature of the tumor. Small papillomata of 
the uterine cavity and the cervical canal can be removed with a sharp 
spoon followed by the use of the Pacquelin cautery (cervix) or of 
a safe caustic (uterine canal). Papillomata of the urethra require in 
their removal the urethroscope. When the tumor has been thor- 
oughly exposed to sight it can be removed by torsion or by linear 
crushing. Papillomata of the bladder can be rendered sufficiently 
accessible to operative removal only by a suprapubic incision. The 
Trendelenburg posture will greatly facilitate the operation. The tumor 
is removed either by torsion, by the wire ecraseur, or, if broad and flat, 
by scraping it away with a sharp spoon or a finger-nail. If the bed 
of the tumor can be exposed sufficiently well to sight and touch, it 



PAPILLOMA AND ONYCHOMA. 



151 



should be cauterized lightly with the actual cautery for the purpose 
of arresting hemorrhage as well as to destroy remnants of the tumor, 
which, if left, would give rise to a speedy recurrence. 

Onychoma. 
Virchow described a papillary tumor of the matrix of nails under 
the name of onychogrypliosis (Fig. 67), and distinguished it from an inflam- 
matory hyperplasia occupying the same locality, which he called onycho- 
mycosis. A papillary tumor of that part of the cutaneous surface occu- 
pied by the nails resembles in structure and in physical appearance the 
cornu cutaneum. Such a tumor is composed almost exclusively of the 
product of epithelial proliferation, and it has a vascular base. A true 
nail-horn usually appears clinically as a single tumor, while the inflam- 
matory swelling, onychogrypliosis, is a multiple affection attacking at the 
same time or in succession a number or all of the nails of both hands. 




Fig. 67. — Onychogryphosis of toes ; natural size (after Ziesing). 



The inflammatory form of onychoma is extremely common in the toes 
of bedridden patients, especially old women and those who are filthy. 
The true onychoma occurs in persons in perfect health and under the 
best sanitary and hygienic conditions. The nail often reaches several 
inches in length and becomes curved, resembling a ram's horn. The 
writer removed a nail of this kind which was three inches in length. 
A recurrence of the tumor can be prevented with certainty only by 
extirpation of the whole matrix of the nail. 



XIV. ADENOMA. 

Adenoma is a benign epithelial tumor which in structure resembles 
the glandular tissue of the organ in which the tumor is located. Ade- 
noma is the second variety of benign tumors of the epiblast and the 
hypoblast. The relation of the epithelial cells to the basement membrane 
is the reverse of that of papilloma ; that is, the basement membrane is on 
the outside of the parenchyma of the tumor, instead of on the inside, as 
is the case in papilloma. In papilloma of the cutaneous and mucous 
surfaces the cellular elements of the tumor often become detached and 
permanently lose their connection with the tumor ; in adenoma the cells 
arc confined in hollow spaces bounded by the basement membrane , and 
they or the miabsorbable products of their regressive metamorphoses 
remain permanently as a part of the tumor. These differences in the 
anatomical structure of the tumor will go far to explain why a papil- 
loma never attains a large size, and why the size to which a rapidly- 
proliferating adenoma may attain is unlimited. In reference to the 
relation of the tumor-cells to the subcutaneous or submucous connec- 
tive tissue, there exists a great analogy between papilloma, epithe- 
lioma, adenoma, and glandular carcinoma. An adenoma, as its name 
implies, is a glandular tumor. Broca included under the term " ade- 
noma " all circumscribed glandular swellings. Cornil and Ranvier 
embraced in this class only glandular tumors composed of new gland- 
ular tissue. In the strictest etiological and pathological sense the term 
should be limited to glandular tumors containing adenomatous tis- 
sue produced from a tumor-matrix independently of the pre-existing 
glandular tissue. As adenoma is present in all the glandular organs, 
the cells of which it is composed resemble the type of cells of the 
gland or duct in which the tumor is located. Glandular tumors, how- 
ever, are found in localities where glands do not normally exist. In 
such instances the tumor develops either from a matrix of embryonic 
cells displaced and isolated during fetal life — the so-called " rests " — or 
from a matrix of embryonic cells in a supernumerary or accessory 
gland. Such accessory glands are found in the vicinity of nearly all 
the glandular organs, notably the thyroid, pancreas, spleen, liver, kid- 
neys, and mammary gland. Adenomata are found quite often in the 

152 



ADENOMA. 



^st 



axillary space unconnected with the mammary gland. A fetal matrix 
in the vicinity of the umbilicus, derived from the intestinal tract, may 
give rise to adenomata representing intes- 
tinal glands. Tumors of this kind were ob- 
served by Kiistner and Heukelem, and were 
freely supplied with unstriped muscular fibres. 
Glandular tumors springing from a post-natal 
matrix of embryonic cells are necessarily 
confined to normal or accessory glands. 

The histological similarity between an 
adenoma and the normal tissues in which 
such a tumor may be located is well shown 
in Figures 68 and 69. The difference be- 
tween an adenoma and normal gland-tissue, 
from a physiological standpoint, is best shown by tumors of glands 
in continuous physiological activity, such as the liver and the kidneys, 
from the absence of gland-ducts and the presence of an atypical in 
place of a typical circulation. 




Fig. 68. — Transverse section of 
follicles of large intestine of dog : the 
individual tubules are separated by the 
fibrous stroma of the mucosa (after 
Piersol). 




Fig. 69 



— Polypus (adenoma) of rectum, showing the glands of the tumor; X 35° (after D.J. Hamilton) 
a, gland lined by columnar epithelium; />, stroma of the tumor. 



Histology and Pathology. — -The histogenesis of adenoma has been 
referred either to a congenital matrix of embryonic cells in glandular 
organs, accessory glands, or displaced islets of embryonic cells (hetero- 
topic), or to embryonic cells of post-natal origin in glands and acces- 
sor)' glands. Like the papilloma, it receives its stroma and its blood- 
supply from the mesoblast. The glandular part of a tumor remains 
in an adenoma permanently. The most important distinctive feature 



154 



PATHOLOGY AND TREATMENT OF TUMORS. 




between a localized or diffuse hyperplasia of a gland and an adenoma 
is the absence of function in the latter in common with all other tumors. 

The absence of ducts prevents 
the escape of the products of 
cell-proliferation, frequently re- 
sulting in the formation of cysts 
the contents of which vary ac- 
cording to the nature of the 
degenerative processes which 
occur in the cells of the paren- 
chyma of the tumor. Tumors 
in the interior of internal organs, 
as a rule, attain greater size than 
tumors of the cutaneous or the 
mucous surfaces. Adenoma of 
the breast seldom exceeds the 
size of a walnut. The essential 
structure of an adenoma is the 
stroma of fibrous or myxoma- 
tous connective tissue contain- 
ing newly -formed glands of 
either the acinous or the tubu- 
lar variety. A central space be- 
tween the epithelial cells can invariably be found, representing the 
glandular spaces in normal glands. 

Most of the myxomatous polypoid growths are glandular tumors. 
Adenoma containing tubular glands presents on section under the mi- 
croscope the appearance of tubular glands (Fig. 70). The cells are 
arranged in a single layer or in stratified layers ; the centre of each 
tubule shows a space toward which the unattached parts of the cells 
converge. 

Adenoma composed of acinous glandular tissue shows on section 
under the microscope spaces lined by flat epithelial cells (Fig. 71). The 
stroma varies in amount : if abundant, the tumor is hard ; if scanty, soft. 
The blood-vessels follow the stroma and supply each tubule or acinus 
of the tumor with an irregular network of capillary vessels. The cells 
of an adenoma are subject to fatty, mucoid, and colloid degeneration. 
The stroma frequently undergoes myxomatous degeneration. The 
progressive accumulation of the degenerated products of cell-prolifera- 
tion leads to cyst-formation. Such cysts vary in size from micro- 
scopical spaces to cavities which contain many quarts of fluid. The 
largest cysts are found in, or in the vicinity of, the ovary. The fetal 



Fig. 70. — Section of an adenoma from a child's rectum 
highly magnified (after Sutton). 



ADENOMA. 



155 



remains of ducts in the vicinity of the ovary give rise to the formation 
of adenoma containing tubular structures the vegetative power of 
which is much greater than that of the Graafian follicles. The liability 
of an adenoma to become transformed into a glandular carcinoma is 




Fig. 71. — Adenoma of mammary gland; X 50 (after Karg and Schmorl): a, epithelial cells lining gland-space; 

b, glandular space ; c, stroma. 

perhaps greater than that of papilloma. In fact, according to D. J. 
Hamilton, carcinoma is preceded by an adenomatous stage (Fig. 72), 
an opinion advanced years ago by Gouley of New York. The earliest 
evidences that such an occurrence has taken place are a more active 
multiplication of epithelial cells and their migration through the base- 
ment membrane into the connective tissue outside the limits of the 
tumor (Fig. 72, b). 

Etiology. — The essential cause, the matrix of embryonic cells, has 
been referred to in the introductory remarks of this section. Of the 
exciting causes, trauma, irritation, and inflammation are the most influ- 
ential. Adenomata are found most frequently in organs the seat of peri- 
odical congestion, such as the mammary and prostate glands, the uterus, 
and the ovaries. They are common also in mucous passages the seat of 



156 



PATHOLOGY AND TREATMENT OF TUMORS. 




catarrhal affections, such as the nasal cavities and the rectum. Adenoma 
is met with most frequently in the young and in persons not beyond 

middle life. The greater frequency 
of adenoma of the ovary as com- 
pared with that of the testicle is ex- 
plained by Klebs upon the ground 
that in the testicle the structures 
retain their fetal arrangements, 
while in the ovary they are trans- 
formed into isolated structures, the 
Graafian follicles. During the re- 
arrangement of the structures of 
the ovary in the embryo tubular 
remnants not utilized in the forma- 
tion of the Graafian follicles are 
set aside, and remain as fetal rests 
from which later the large adeno- 
matous cysts take their origin. 

Topography. — The topograph- 
ical distribution of adenomata fur- 
nishes an interesting proof of the 
importance of exciting causes in 
the production of tumor-growth. 
We shall find that benign glandular tumors frequent localities and 
organs the seat of prolonged vascular fluxions and exposed to inter- 
current affections which are 
calculated to diminish the phys- 
iological resistance of the tis- 



Skin. — Adenoma of the skin 
is represented by the two kinds 
of glands found in this struct- 
ure, the sebaceous and the su- 
doriparous glands. Retention- 
cysts of these glands are of 
course excluded from present 
consideration. True adenomata 
of the skin are veiy rare. 
Sebaceous glands found in other tumors, such 

Liicke 



Fig. 72. — Development of a cancer of the mamma : 
a set of adenomatous acini becoming cancerous ; X 350 
(after D. J. Hamilton): a, an adenomatous swelling 
of an acinus ; b, the cells of a similar swelling which 
have broken out and are invading the surrounding 
stroma; c, part which is cancerous. 




Fig. 73. — Isolated sebaceous adenomata (after Demme). 



Adenoma Sebaceum.- 
as dermoid cysts, are not tumors, but hyperplastic glands, 
removed an ulcerating sebaceous tumor from the nose of a man eighty 
years old. He suspected that the tumor was a carcinoma, but micro- 



ADENOMA. 



157 



scopic examination showed only convolutions of sebaceous glands and 
interglandular connective tissue — no trace of carcinoma. The tumors 
when small assume the shape of sebaceous glands. In larger tumors 
the glandular tubules form a convoluted mass. Demme described a 
large sebaceous adenoma of the skin of the scrotum. The few cases 
of sebaceous adenoma that have been reported appear to show that this 
tumor is found almost exclusively in the aged, and that the face and 
the scrotum are its favorite localities. Anatomically, this tumor is dis- 
tinguished from a retention-cyst by the presence of numerous tubules 
instead of one cavity, as is the case in retention-cysts (Figs. 73, 74). 






W*W 









Fig. 74.— Sebaceous adenoma from the skin of the left side of the neck : upon the summit of the separate 
nodules the dilated outlets of the ducts can be seen (after Demme), 

Adenoma Sudoriparum. — Sudoriparous adenoma was first described 
by Verneuil. Virchow's doubts regarding the existence of such a tumor 
have not been confirmed by later investigations. Lotzbeck observed a 
case in which the tumor was congenital. In Thierfelder's case the 
tumor occupied the diploe, but communicated with the skin, in which 
it undoubtedly had its origin. The growth of the tumor takes place 
from the deeper part of the tubule, which elongates and becomes more 
convoluted than normal sweat-glands (Fig. 75). According to Verneuil 
and Demarquay, these tumors may reach the size of a fist, and may 
manifest a great tendency to ulceration ; the}' have been mistaken for 
angioma. The growth of the tumor is slow. Sweat-gland adeno- 
mata have been observed most frequently upon the skin of the face. 



158 



PATHOLOGY AND TREATMENT OF TUMORS. 



Demarquay saw such a tumor the size of an egg in the axillary space ; 
Verneuil, one upon the sternum and one upon the back. 

Digestive Tract. — Adenomata of the cavity of the mouth are rare. 
In the stomach adenoma occupies most frequently the pyloric part, and 




Fig. 75. — Sudoriparous adenoma from skin of frontal region of a woman ; transverse section of tubule, 
X 650 (after Lucke) : a, hair-follicle ; b, adipose tissue; c, sweat-glands in longitudinal section; d, d" , the 
same in transverse section. 



may attain the size of a hen's egg and cause pyloric obstruction. It is 
more frequent in the intestinal mucous membrane, and is often the 
direct cause of invagination. The mucous membrane of the rectum is 
more frequently affected by adenoma than is the remaining part of the 
whole intestinal tract. The majority of cases of polypus in this local- 
ity have an adenomatous structure. Nearly all the adenomata of the 
mucous membrane lining the gastro-intestinal canal present in section 
under the microscope a tubulated appearance. Adenoma of the rectum 
(Fig. 76) is more frequent in children than in adults. The tumor in- 
creases slowly in size, and in the course of time becomes pedunculated. 



ADENOMA. 



1 59 



Adenomata in this locality usually vary in size from that of a cherry 
to that of a walnut. At the base of the tumor or pedicle the mucous 
membrane of the tumor is continuous with that of the rectum. The 
symptoms are the same as in papilloma. 

Nasal Cavities. — Many of the polypoid growths of the nasal cavi- 
ties are adenomata. Billroth was the first to discover gland-follicles 




Fig. 76. — Adenoma of the rectum ; X 48 (after Karg and Schmorl). The tumor is composed of glandular 
spaces and, between them, a stroma infiltrated by small cells. The structure of the tubules corresponds with 
that of the normal glands of the rectum. The glandular spaces are lined with columnar cells with basal 
nuclei surrounded by the membrana propria. Between the columnar cells here and there can be seen goblet- 
cells ic). Some of the glands are enlarged and are supplied with lateral buds ; others are transformed into 
larger hollow spaces (a). At /' dilated blood-vessels are seen in the stroma. 



in the myxomatous polypus of the nose. The connective tissue sur- 
rounding the adenomatous growth and the epithelial cells of the mu- 
cous membrane covering the tumors are in a hyperplastic condition, 
caused by an increased blood-supply. Adenoma of the nasal mucous 
membrane often appears as a multiple affection. Catarrhal inflamma- 
tion often precedes, and frequently attends, adenoma of the nose. 

Uterus and its Appendages. — The uterus is the organ most frequently 



i6o 



PATHOLOGY AND TREATMENT OF TUMORS. 



affected by adenoma. The development of the tumors in this locality- 
is usually preceded by catarrhal inflammation. The inflammation evi- 
dently acts as an exciting cause in diminishing the physiological resist- 




Fig. 77. — Adenoma of the posterior wall of the uterus (after Winckel). 

ance of the tissue in the vicinity of the embryonic matrix. The fungous 
vegetations which so often cover the cervix uteri and its canal — the 
so-called " erosions " — are either papillomata (see Fig. 66) or adenomata. 




Fig. 78. — Uterine cavity entirely filled with adenomatous vegetations (after Winckel). 

In the uterine cavity adenoma is found as a single tumor or in the form 
of diffuse vegetations covering the entire surface. Adenoma of the 
uterine cavity (Figs. Jj, 78) or of the cervix seldom increases beyond 
the size of a walnut. The tumor appears first as a small nodule, 
pushes the mucous membrane before it, and, if it increases to the 



ADENOMA. 161 

size of a cherry, becomes pedunculated. Multiple adenomata of the 
uterine mucous membrane usually remain sessile. Menorrhagia, a pro- 
fuse glairy discharge, and dysmenorrhea are some of the most promi- 
nent symptoms which point to the existence of adenomata of the 
mucous membrane lining the uterus. 

Adenoma of the Fallopian tubes is a very rare affection. Ascites 
is sometimes produced by tumors in this locality, as the increased 
secretion provoked by the tumor escapes into the peritoneal cavity. 

Adenoma of the ovary, according to Waldeyer, Thierfelder, and 
Klebs, does not originate from the Graafian follicles so frequently 
as was formerly believed. In the majority of cases the tumor starts 
from an embryonic tubular matrix, a remnant of Pfliiger's ducts. 
Glandular tumors of the ovary appear as globular, nodular tumors of 
widely different form and size. Some of these tumors become so large 
that they exceed the weight of the patient. They develop beneath the 
columnar epithelial cells of the surface of the ovary, within a strong 
layer of connective tissue in which are imbedded the blood-vessels. 
In the centre of this vascular connective-tissue layer a small space 
lined with cylindrical cells marks the beginning of the adenoma and 
the incipient formation of a cyst. Waldeyer claimed that the glandular 
spaces are lined by only one layer of epithelial cells, while Rindfleisch, 
Bottcher, and others found several layers. Into a space thus formed 
other tubules project and open, forming secondary cysts. If the walls 
of the secondary cysts, by distention and growth, come in contact, the 
joint septum formed breaks down and a communication between the 
cysts is established. Coalescence of many cysts in this manner may 
result in the formation of enormous spaces. Cruveilhier and Virchow 
found in the jelly-like, structureless contents of such cysts blood- 
vessels, the remnants of the broken-down septa. For this kind of 
glandular cysts Waldeyer proposed the name " myxomatous cysts." 
In typical adenoma of the ovary the cysts do not reach such great 
size. Constant friction on the surface of the tumor destroys the epithe- 
lial layer and leads to adhesions, which in cases of glandular cysts are 
often very extensive and firm. From the cyst-wall form buds covered 
by cylindrical epithelium, projecting into the cyst and presenting the 
appearance of placental villi (see Fig. 60). These papillary intracystic 
growths carry with them large vessels and take a very active part in the 
proliferation of tumor-tissue. By perforation of the cyst-wall these 
papillary excrescences reach the peritoneal cavity, and undoubtedly 
have much to do with the production of ascites, which so often attends 
this form of ovarian tumor. The small cysts contain a jelly-like, homo- 
geneous substance. The larger the cyst the more liquid its contents. 
11 



162 



PATHOLOGY AND TREATMENT OF TUMORS. 



Waldeyer and Spiegelberg found in all cysts of the ovary paral- 
bumin. 

Thyroid Gland. — The thyroid is one of the ductless glands. It is 
only recently that its physiological importance has been ascertained 
definitely. Clinical observation and experimental research have demon- 
strated that the complete destruction of the gland by disease or its 
removal by extirpation results in myxedema and cretinism. It is a 
compound tubular gland, whose excretory duct, the thyro-glossal duct, 
in the early stages of the organ connects the tubules with the mucous 
surface, where its opening corresponds to the foramen caecum. It is 
along this tract that remnants of the gland are occasionally found, as 
well as accessory glands in the vicinity of the organ, which may become 
the seat of adenomata resembling the structure of the thyroid gland. 
This gland in its normal condition contains the product of one of the 
retrograde tissue-metamorphoses — colloid material. It would appear 

that this tendency of the cells to degen- 
eration into colloid material in a normal 
condition would naturally predispose 
adenomata of this organ to the forma- 
tion of cysts. Virchow divided the 
benign tumors of the thyroid gland 
into — (i) Struma hyperplastica ; (2) 
struma gelatinosa ; (3) struma cystica. 
This classification is no longer tenable, 
as the gelatinous and cystic varieties 
represent only an advanced stage of 
adenoma. 

The ordinary bronchocele, mias- 
matic struma, is not a true tumor, but 
an infective swelling caused by an unknown microbe. Enlargement of 
the gland from this cause is an endemic affection. The true glandular 
tumor of the thyroid is produced, like other tumors, from a matrix 
of embryonic cells. It is in this gland that the essential cause of 
tumor-formation has been actually demonstrated. Wolfler has found, 
in the substance of the gland, cell aggregations which did not appear to 
belong to the gland-structure and which he regarded as remnants of 
embryonic tissue. From these develop the adenomata. He formulates 
adenomata as " epithelial new formations which develop from embryonal 
gland-matrices with atypical vascularization." Wolfler has shown that 
the true benign tumor of the thyroid gland is an adenoma. The 
greater prevalence of adenomata in districts inhabited by miasmatic 
struma is an important proof of the part taken by the surrounding 




Fig. 79. — Section of thyroid body exhibiting 
detail of acini, which are cut in various direc- 
tions (after Piersol) : c, colloid material distend- 
ing the larger acini; i, interacinous connective 

tissue; v, blood-vessels. 



ADENOMA. 



16- 



tissues in tumor-formation. The physiological resistance of the tissue: 
is diminished by the infective process, and matrices of embryonic cell: 
which have remained in a latent state until then assume active tissue 
proliferation and produce a true glandular tumor. 

The difference between an infective swelling of the thyroid gland anc 
a true tumor has already been pointed out. A miasmatic swelling 
yields to the internal and external use of iodine preparations ; a trui 
tumor is not affected by this treatment. Early treatment of a miasmati 
struma is a prophylactic measure against tumor-formation, as it restore, 
the physiological resistance impaired by the microbes which produced th 
struma. The glandular tumors are always imbedded in the substano 
of the gland or in the miasmatic struma, and are encapsulated. Fre 
quently they are multiple. Small recent cysts always contain a colloii 
substance. Multilocular cysts are formed in the same manner as ii 
cystic adenoma of the ovary, by coalescence of two or more cysts. Ii 




Fig. 80.— Enormous tumor of the thyroid gland (after Bruns). 

old cysts the contents become more liquid, and are often changed othei 
wise by hemorrhage into the cyst and by the formation of numerou 
'Cholesterin-crystals. Other forms of regressive metamorphosis ar 



1 64 PATHOLOGY AND TREATMENT OF TUMORS. 

amyloid, cheesy, and fatty degeneration and calcification. The tumors 
often attain great size. Rose has shown that death from sudden suffo- 
cation is caused by atrophy and softening of the tracheal rings resulting 
from pressure of the tumor. The trachea in such cases has been found 
flattened, resembling a sabre-sheath. Pressure-atrophy and flattening 
of the trachea do not take place in proportion to the size of the tumor. 
A small tumor, not larger than a hen's egg, of the middle lobe of the 
gland will do more damage to the trachea than will a large tumor, such 
as that shown in Figure 80. When a tumor has attained this size 
pressure-symptoms are often relieved by the weight of the tumor 
making traction away from the trachea. Retro-sternal tumors give rise 
to the most distressing symptoms, as the outward growth of the tumor 
is opposed by the unyielding sternum. Retro-tracheal tumors or 
tumors encircling the trachea are also the source of great suffering, and 
demand operative treatment. It is generally known that adenoma of 
the thyroid gland shows no tendency to increase in size after the patient 
has reached his fiftieth year. Numerous cases of congenital tumors of 
the thyroid gland have been recorded. They are most likely to occur 
in localities where bronchocele is endemic. 

If, in a person past middle life, a struma that has been stationary 
for years suddenly and without any special provocation commences to 
increase in size, it is very probable that the tumor has undergone 
transformation into a carcinoma or a sarcoma. Malignant disease of 
the thyroid gland is more likely to originate in a pre-existing tumor 
than in a normal gland. Tumors of the thyroid gland always receive 
a rich blood-supply. The gland is so abundantly supplied with blood 
from the four thyroid arteries that excessive vascularization of the 
tumor invariably occurs. The veins of the capsule of the gland, if 
the tumor is large or multiple, often attain the size of the little finger; 
the superficial veins in such instances are also enormously dilated (see 
Fig. 80). 

The differential diagnosis in tumors of the thyroid gland has for its 
object to distinguish between infective swelling, adenoma, cyst, carci- 
noma, and sarcoma. A miasmatic bronchocele presents itself as a 
smooth swelling involving usually the entire gland. It is endemic in 
certain districts in some countries (Switzerland and Austria), and it 
appears usually during childhood or at the age of puberty. A few 
weeks' treatment with preparations of iodine will make an impression 
on the swelling. Adenoma commences as a small nodule in the sub- 
stance of the gland, and follows the movements of the gland during 
deglutition. Adenoma is often multiple from the beginning, or addi- 
tional nodules appear in different parts of the gland in succession. 



ADENOMA. 165 

Sarcoma and carcinoma develop in preference in a gland affected pre- 
viously by infective swelling or by adenoma, and occur, as a rule, in 
adults and in persons of advanced age. The malignant tumors grow 
rapidly in size, and soon render the tumor immovable by extension to 
the surrounding tissues. Cysts frequently mark an advanced stage 
of an adenoma. Unless the cyst-wall is very tense, fluctuation can be 
elicited without difficulty. If any doubt exists, an exploratory puncture 
will furnish the desired information. A miasmatic swelling or an ade- 
noma of the thyroid gland is prone to become the seat of microbic infec- 
tion during an intercurrent infective disease. Tavel studied this subject 
very exhaustively from a bacteriological aspect, and reported a number 
of cases of strumitis in which he found in the inflamed tumors microbes 
similar to those which caused the general infective disease, notably 
typhoid fever. 

Treatment. — Owing to the importance of the operative treatment 
of tumors of the thyroid gland, this subject will be discussed separately. 
The most efficient treatment of miasmatic bronchocele is by the internal 
and external use of iodine. The parenchymatous injections of iodine 
so extensively used by Liicke are no longer popular. It has been fol- 
lowed by disastrous results in a number of instances. Paralysis of the 
recurrent laryngeal nerve, great swelling, and suppuration are some of 
the immediate complications occasionally caused by this method of 
treatment. The late Professor Gunn used parenchymatous injections 
of a 5 per cent, solution of carbolic acid, repeated once or twice a week, 
with great success, and this method has remained in constant use in 
the clinic of Rush Medical College, and is yielding excellent results. 
It is perfectly safe, almost painless, and the carbolic acid appears to 
neutralize the primary microbic cause. The iodine treatment is em- 
ployed at the same time. The injection should be made into different 
parts of the tumor, and should be repeated at least twice a week. 

Extirpation of the thyroid gland for tumor is a comparatively recent 
operation. J. Collins Warren of Boston extirpated one lobe of the thy- 
roid gland, after preliminary ligation of the common carotid artery on 
the same side. He believed that the operation was impracticable with- 
out resorting first to tying of the common carotid artery. Green prac- 
tised rapid removal of the tumor, and ligated the bleeding vessels later. 
Rose tied each vessel before cutting, proceeding very slowly. The 
writer in 1878 witnessed one of his operations, which lasted for four 
hours. The operative technique of strumectomy has been perfected 
chiefly by the teachers of surgery in the universities of Switzerland — 
Billroth, Liicke, Julliard, Reverdin, Socin, and Kocher — men who 
were frequently called upon by patients from localities in which 



166 PATHOLOGY AND TREATMENT OF TUMORS. 

bronchocele prevailed as an endemic affection. Kocher was the first 
to call the attention of the profession to the evil results following- 
complete removal of the thyroid gland. He observed, in a number of 
cases in which he removed with the tumor the entire gland, a condition 
which he termed cachexia strumipriva, which resembled what was later 
discovered to be myxedema. This subject then received careful ex- 
perimental investigations which corroborated Kocher's observations. 
Zesas found in his experiments on dogs that if only a part of the gland 
is extirpated the remaining part undergoes compensatoiy hypertrophy 
and that complete removal of the gland resulted sooner or later in the 
death of the animal. Similar experiments with the same results were 
made by Bardeleben and Horsley. The experiments have taught sur- 
geons that complete extirpation of the thyroid gland except for malig- 
nant disease is an unjustifiable operation. A part of the gland must be 
allowed to remain in order to prevent the probable occurrence of serious 
remote complications. 

Partial extirpation of the thyroid gland is still in use in the removal 
of benign growths, and complete strumectomy is absolutely necessary 
in the extirpation of malignant tumors. The external incisions selected 
for this purpose must be made in accordance with the size and location 
of the tumor. An incision along the margin of the sterno-cleido- 
mastoid muscle will secure good access for the removal of tumors or 
for extirpation of the lateral lobes. A median incision will reach tumors 
of the isthmus most directly. In large tumors or in tumors involving 
both lobes a transverse incision over the most prominent part of the 
tumor, with the concavity directed upward, is preferable. So far as pos- 
sible, the vessels should be ligated or be secured with pressure-forceps 
before being cut. This ligation is especially necessary when the thyroid 
arteries are reached. The isthmus of the gland is included in a ligature 
en masse. The operation should be performed slowly and carefully, and 
all tissues should be identified before being cut, to avoid injury to the 
recurrent branch of the pneumogastric nerve. Accidental section of 
this nerve is followed by paralysis of the vocal cords on the same side, 
which paralysis will in all probability remain as a permanent disability. 

Extirpation of parts of the thyroid gland has largely given way to 
enucleation, an operation devised by Socin and strongly endorsed by 
Julliard. It is the ideal operation, as it leaves the gland-tissue intact. 
This operation is not limited to the removal of small growths, as the 
enormous tumor depicted in Figure 80 was successfully removed by 
the same procedure. All glandular and cystic tumors of the thyroid 
gland are enclosed by a thick connective-tissue capsule which can be sep- 
arated from the surrounding tissues with ease and without much hemor- 



ADENOMA. 167 

rhage. The great secret in the successful removal of glandular and 
cystic tumors of the thyroid gland is to find the exact place, between cap- 
sule and tissues, at which to commence the enucleation. The dissection 
down to the capsule must be made with the utmost care, and no attempts 
at enucleation should be made until the proper place is found. As soon 
as the capsule is reached the knife must be laid aside and the tumor 
be enucleated by the use of the finger or of blunt instruments. The 
parenchymatous hemorrhage generally yields to pressure and hot water, 
or, in case it is not controlled in this way, to the aseptic tampon. If 
the aseptic tampon is not used, the mantle of thyroid tissue which was 
cut in exposing the tumor should be sutured with absorbable material 
separately before closing the external wound. If the tampon is em- 
ployed, it is removed at the end of the first day and the wound is closed 
by secondary sutures. If more than one tumor is found, all the tumors 
can be removed through the same external incision by approaching 
them through separate incisions through the capsule or veil of gland- 
tissue which invariably covers them. The great advantages of enucle- 
ation over extirpation are greater ease of operation, less liability to 
troublesome hemorrhage, less deformity, and, lastly, that it does not 
deprive the patient of any normal gland-tissue, which has been found 
of such enormous importance in the preservation of health. 

Wolfler revived the operation of ligating the thyroid arteries in the 
treatment of tumors of the thyroid gland. This operation, of course, 
can attain what is claimed for it only in parenchymatous tumors. Cysts 
should invariably be enucleated unless calcification of the capsule has 
so far advanced as to render this procedure impracticable. Adenomata 
should be dealt with in the same manner unless the capsule of the 
tumor has become firmly attached to its surrounding tissues by an 
antecedent inflammation. Extirpation should be limited to tumors that 
cannot be enucleated, and it should never include the entire gland except 
in the removal of malignant tumors. 

Mammary Gland. — The benign tumor most frequently met with in 
the mammary gland is the adenoma. Until quite recently it was gen- 
erally conceded that the firm tumors of the mammary gland were in 
the majority of cases fibromata. Careful study under the microscope 
of sections from such tumors has shown that glandular elements 
are absent only in exceptional cases, and consequently that most of 
the benign tumors of the gland are not fibromata, but adenomata. 
Schimmelbusch has shown that the tumors of the breast heretofore 
designated as fibromata are in reality tumors in which the adeno- 
matous structures predominate — an opinion strongly supported by 
Haeckel. In order to realize the true nature and structure of such 



i68 



PATHOLOGY AND TREATMENT OF TUMORS. 



tumors it is absolutely necessary to cxami}ie sections from different 
parts of the tumor. Some sections from the same specimen will often 
show epithelial cells almost exclusively, while other sections exhibit 
only fibrous tissue. The presence of epithelial cells in different parts 
of the tumor, however, leaves the impression that they take the essen- 
tial part in the production of the tumor. Billroth denied that epi- 
thelial cells took any part in the origin and growth of tumors of the 
breast, which he designated as fibroid tumors. The adenoid structure 
is well marked in the tissues of young tumors, while in old tumors 
the epithelial cells are found arranged in an irregular manner in the 



: ^/#^^P?:V 



Y'f<, 



w&m^^ : '^ 



w 



Mtf" 









■-S> s^^ 






Fig. 81.— Adenoma of mamma (after Haeckel) : a, fibrous tissue; £, epithelial cells. (Zeiss, Obj. A., Oc. 2.) 

connective-tissue spaces. Figure 81 shows that the connective tissue 
has separated the acini, but the glandular appearance is well preserved. 
The fibrous tissue is increased by active proliferation of the interacinous 
connective tissue, and the new elements impart to the tissues a grayish- 
red or yellowish color instead of the pearly-white color of old connec- 
tive tissue. At some points in the older portions of the tumor the 

fibrous tissue is pale and firm, at others 
cedematous or myxomatous. 

It is a question whether pure fibromata 
ever occur in the mammary gland. Un- 
mixed adenomata are also exceedingly rare. 
Haeckel had an opportunity to remove and 
examine a pure adenoma of the breast, and 
he gives the accompanying illustration (Fig. 
82) to explain its histological structure. The 
tubules were lined by at least twenty strata 
of epithelial cells. 

The writer removed a tumor the size of a 
hazelnut from the breast of a young lady, and from its firmness 




Fig. 82. — Pure adenoma of the 
mammary gland (after Haeckel). 
(Zeiss, Obj. D., Oc. 2.) 



ADENOMA. 



169 



was led to believe the tumor to be a fibroma. The macroscopical 
appearance of a section of the tumor showed wavy bundles of connec- 
tive tissue, thus confirming the opinion formed. Under the microscope 
the tumor revealed itself as a genuine adenoma. The microscopic ap- 
pearance of the tumor-tissue and the relative proportion of glandular 
and connective tissue are shown in the accompanying illustration (Fig. 
83). It will be seen from this illustration that, although the tumor had 
existed for several years, the tubules are lined by a number of layers 
of epithelial cells and that the glandular spaces are small. We have 

















«K3!&$fc 



Fig. 83. — Adenoma of breast ; X 115. reduced one-fifth (Surgical Ciinic, Rush Medical College, Chicago) : a, 
shrinkage due to hardening; b, proliferating ducts ; c, fibrous tissue. 

reason to believe that during the future growth of such a tumor the 
stroma would increase more than the parenchyma, and so render 
the fibrous structure more apparent. Adenomata without cyst-forma- 
tion never attain a large size. Usually they range 
in size from that of a pea to that of a walnut ; 
99 per cent, of them occur in females. Adeno- 
mata occupy more frequently the superficial and 
peripheral than the deep and central parts of 
the gland. They are often multiple in one breast, 
seldom in both breasts. They often cause great 
pain and are quite tender on pressure. These Astiey Cooper) 
symptoms are much less prominent in the early 
history of carcinoma of the breast. Adenoma of the breast (Fig. 84) 
is always well encapsulated. Adhesion to the skin and retraction are 




Fig. 84. — Adenoma of the 
breast, showing capsule (after 



170 PATHOLOGY AND TREATMENT OF TUMORS. 

therefore never observed. The existence of a well-defined capsule is 
of great assistance to the surgeon in doubtful cases after he has exposed 
the tumor to make a positive diagnosis of its non-malignant nature. A 
section of the tumor (Fig. 85), if the fibrous tissue predominates, very 
much resembles in its naked-eye appearances fibroma of the uterus. 
The surface of the section appears as though the tumor were composed 
of separate parts, each of which indicates a different centre of growth. 
Cystic adenoma often attains great size. The contents of the cysts are 
variable. Colloid degeneration seldom takes place. The serous fluid is 




Fig. 85. — Large adenoma of breast, cut surface resembling fibroma of tbe uterus (after Astley Cooper). 

often stained a dark color, owing to the presence of blood and cholesterin- 
crystals. The writer has found cystic degeneration most frequent in 
women advanced in years. In the diagnosis it is important to remem- 
ber that carcinoma seldom, if ever, occurs in the breast as a multiple 
affection, while this is frequently the case in adenoma. Retraction of 
the nipple and the skin may follow inflammatory affections of the 
breast, but is never present in uncomplicated adenoma, and is of fre- 
quent occurrence in carcinoma. Adenoma resembles more closely 
sarcoma than carcinoma. Sarcoma, however, grows much more rapidly 
than carcinoma, and is usually attended by dilatation of the superficial 
veins. Adenoma and sarcoma occur frequently in young adults, while 
carcinoma is seldom met with in women less than thirty-five years 



ADENOMA. 



171 



of age. The prognosis must always be guarded, as adenoma of the 
breast undergoes transformation into malignant tumors — carcinoma and 
sarcoma — perhaps more frequently than any other benign tumor. Early 
operative removal should be recommended, as an operation brings 
mental as well as physical relief, and protects the patient against the 
possibility of the occurrence of malignant disease caused by the transi- 
tion of a benign into a malignant tumor. 

Prostate Gland. — The prostate is a glandular organ and part of 
the genital apparatus. It was until recently supposed that the en- 
largement of this gland in men past fifty years of age was a tumor 
resembling myofibroma of the uterus. This idea, in the light of recent 
investigations, has been abandoned, and the enlargement is now regarded 
as a glandular swelling or tumor. White of Philadelphia ascertained 
by his experiments on dogs that castration resulted almost uniformly 
in great diminution in the size of the prostate. Surgeons have made 
use of the knowledge thus gained, and in a few instances have resorted 
to castration for the relief of enlargement of the prostate gland. Ramm 




Fig. 86.— Median prostatic adenoma, sketched from within the bladder (after Sutton). 



of Christiana reports two cases in which this operation afforded perma- 
nent relief and was followed by progressive diminution in the size of the 
gland. Harrison of London reports a case of hypertrophy of the pros- 
tate greatly benefited by subcutaneous section of the spermatic cord on 
both sides. The patient begged to have castration performed, and as 
a compromise Harrison made subcutaneous section of both cords. 
Should future operations produce similar results, they would prove 
that in the majority of cases enlargement of the senile prostate is not 
a tumor, but a swelling. The writer is firmly convinced that in most in- 



172 PATHOLOGY AND TREATMENT OF TUMORS. 

stances this is the case. There is, however, a tumor of the prostate that is 
glandular in structure and that appears as a single or a multiple affection 
involving any or all of the lobes of the gland (Fig. 86). The general 
enlargement of the gland consists of a hyperplasia of the glandular 
and connective-tissue part of the gland; the isolated nodules are ade- 
nomata. Adenomata are found almost exclusively in hyperplasic glands, 
in this respect bearing a strong resemblance to adenomata of the thy- 
roid gland. The hyperplasia of the organ occurs as one of the many 
pathological conditions incident to old age, in the production of true 
tumors taking the same part as the miasmatic struma. The prostate, 
like the uterus and the thyroid gland, is an organ in which and around 
which complicated developmental changes take place ; consequently 
there is here, as in the other organs mentioned, great liability of the 
deposition of unutilized embryonic cells which later become the essen- 
tial tumor-matrix. So long as the physiological resistance of the tis- 
sues around the matrices remains unimpaired, tumor-growth does not 
take place, but when this resistance becomes diminished by senile debil- 
ity, and particularly by the changes which the prostate undergoes 
during advanced age, the embryonic cells assume active tissue-prolifer- 
ation which results in the formation of a tumor. Billroth asserted that 
he never observed an adenoma in the prostate gland, and he attributed 
the senile enlargement to dilatation of the acini and hyperplasia of the 
epithelial cells. It took a long time for pathologists to make a distinc- 
tion between hyperplasia of the thyroid gland and the adenomata, and 
the same confusion has prevailed in regard to the two entirely different 
kinds of enlargement of the prostate gland. The extirpation of the 
hyperplasic prostate in toto has not yielded encouraging results, and 
will never become a feasible surgical procedure ; on the contrary, enu- 
cleation of adenomata of this organ from the perineum through Zucker- 
kandl's incision or through the bladder above the pubes has a promis- 
ing future. 

Lachrymal Gland. — Adenoma of the lachrymal gland has been 
studied by P. Becker and others. It appears as a lobulated, nodular 
tumor of moderate size, and it is very liable to undergo hyaline degen- 
eration. The tumor increases in size very slowly, and the formation 
of small cysts is of frequent occurrence. Enucleation of the tumor 
should be done in preference to extirpation of the whole gland. 

Parotid Gland. — According to C. O. Weber, the parotid gland is very 
rarely the seat of adenoma. Billroth maintained that adenoma of this 
organ, when it does exist, is only a part of a compound tumor. It cannot 
be denied that compound tumors of the parotid gland, such as adeno- 
chondroma, adeno-cystoma, and adeno-carcinoma and adeno-sarcoma, 



ADENOMA. 



: 73 



are frequently met with in the examination of tumors of this organ. 
Pure adenoma of the parotid gland has, however, been found, and it 
resembles in structure similar tumors of the thyroid gland. Glandular 
tumors occur most frequently in young adults. Cystic degeneration 
often takes place at different points, large cavities being formed by the 
coalescence of smaller cysts. The cyst-wall, lined by epithelial cells, 
often projects into the cysts at different points in the form of papillary 
excrescences. The tumor is well encapsulated, and it can be enucleated 
very readily without serious damage to the gland. The incision should 
be made with special reference to the location and direction of Sten- 
son's duct and the branches of the facial nerve. A thin veil of gland- 
tissue has to be divided before the capsule of the tumor is reached, and 
the operation occasionally results in the formation of a temporary 
salivary fistula. 

Testicle. — The relative proportion of true tumors of the testicle to 
inflammatory swellings is unusually small. Adenoma of the testicle 
has only recently been described. Liicke called attention to its 
existence in connection with cystic disease of the testicle. Eve has 
examined a large number of cysts, including adeno-cystoma, sarco- 
mata, myxomata, and carcinomata ; 
they were lined by columnar, strati- 
fied, or ciliated epithelium ; some 
were papillomatous, and cartilage 
and unstriated muscular fibres were 
occasionally present in the stroma. 
The adeno-myxomata were charac- 
terized by slit-like tubes or solid 
rods of gland-tissue surrounded by 
a zone of transparent tissue. Eve 
and Sutton believe that the majority 
of glandular tumors of the testicle 
originate in the remnant of the 
Wolffian body lying between the 
globus major of the epididymis and 
the testicle proper. This remnant 
of the Wolffian body is known as 
the " paradidymis " (see Fig. 87). 

Adenoma of the testicle is characterized by the existence of numer- 
ous small cysts. The cyst-spaces are lined with columnar or stratified 
epithelium. If the tumor attains large size, it causes atrophy of the 
testicle by pressure. The tumors are encapsulated, but in the few cases 
that have come under the observation of the writer their enucleation 



Paradidymis. 



s tabes. 




Fig. 87. — Diagram to represent the relation of 
the mesonephros and its ducts to the adult testicle 
(after Sutton). 



174 



PATHOLOGY AND TREATMENT OF TUMORS. 



has been found quite difficult. The tumors varied in size from a 
hickory-nut to a walnut, and on section presented a honeycomb appear- 
ance, owing to the presence of numerous cysts, the largest of which 
did not exceed the size of a hempseed (Fig. 88). 

The differential diagnosis of adenoma of the testicle must take into 
consideration tuberculosis, gumma, carcinoma, sarcoma, and circum- 




Fig. 88. — Testicular adenoma (after Sutton). 



scribed hydrocele of the tunica vaginalis. In the removal by enucleation 
great care is required in preventing injury to the cord and the testicle. 
Liver. — Adenoma of the liver during the last year or two has 
become a more interesting topic to the surgeon from the fact that in 
several cases tumors of this kind have been removed successfully by 
excision. Keen and Von Bergmann have each reported a successful 
case. The earliest communications on adenoma of the liver were made 
by Hoffmann and Lancereaux. Gruber, Wagner, and others have 
found detached portions of liver-tissue, often very numerous, in the 
peritoneal folds supporting the liver and in the portal fissure ; these 
fragments may be a possible source of cysts and tumors. Friedreich 
found in the liver itself groups of cells which did not appear to form 
part of the parenchyma, as they were isolated from it by a capsule. 
These embryonic remnants are undoubtedly the matrices from which 
adenomata originate. Isolated tumors may be no larger than a marble ; 
larger tumors are formed by a collection of multiple tumors. In some 
parts of the tumor the seat of active proliferation, metaplastic condi- 
tions of the parenchyma-cells are developed, as in a case reported by 



ADENOMA. 175 

Rindfleisch-Griesinger : the nodules in the acini of this specimen were 




Fig. 89. — Adenoma of the liver (after Paul) : a, section of blind duct filled with green fluid : b, liver-cells ; 

c, connective tissue. 

made up of columnar epithelial cells. Small adenomata, consisting of 
cylinders lined by columnar epithelium and imbedded in fibrous tissue, 






s*« 



X^ 



>U2 



A. 






&>y 






Fig. 90. — Papillary adenoma of kidney ; X 250 (after Karg and Schmorl) : hollow spaces lined by cylindrical 
cells ; stroma scanty and moderately cellular ; papillary proliferations project into the glandular spaces. 

occur (Fig. 89). The acini may be solid and hard, or they may consist 
of large cells and may resemble the acini of the pancreas. A slow- 



176 



PATHOLOGY AND TREATMENT OF TUMORS. 



growing tumor in the substance of the liver in a non-syphilitic subject 
would indicate the necessity of making a careful investigation with a 
view of determining the propriety of an abdominal section to make 
a positive diagnosis, and, if the tumor is found to be an adenoma, to 
attempt its removal. In the cases thus far operated upon a positive diag- 
nosis was made only after the tumor was rendered accessible to direct 
examination by abdominal section. 

Kidney. — The frequency with which the kidney is now subjected to 
operative treatment adds renewed interest to everything pertaining to the 
pathology of the numerous affections of this organ that have recently 
been brought within the reach of successful surgery. Very little is 
known of benign tumors of this organ. Occasionally small cystic 
adenomata are found, some of which are undoubtedly derived from 
retention-cysts, but it is also probable that Wolffian-body rests may be 
a cause. Shattock maintains, with good reason, that remnants from the 
mesonephros (Wolffian body) and the metanephros (true kidney) often 

serve as matrices for tumor- 
formation. The papilloma- 
tous projections into the cysts 
of renal adenomata as well as 
the cyst-wall are covered with 
columnar epithelium which 
bears no resemblance to the 
epithelial cells lining the 
uriniferous tubules (Fig. 90). 
Adenomatous tumors of 
the kidney sometimes reach a 
considerable size in case the 
cysts are large and numerous, 
as in Mr. Edmunds' case (Fig. 
91). The kidney represented 
in Figure 91 was successfully 
removed by Mr. Edmunds 
from a girl eighteen years old. 
Such a tumor might easily 
be mistaken for a sarcoma. 
Diagnosis. — The differen- 
tial diagnosis between ade- 
noma and other glandular 
affections is of great practical importance, often is exceedingly difficult 
owing to the location of the organ affected, and is frequently rendered 
more perplexing by misleading statements on the part of the patient. 




-Adenoma of the kidney (after Edmunds). 



ADENOMA. 177 

Chronic infective swellings, tuberculosis, and gumma are most likely 
to be mistaken for adenoma. Mistakes of this kind have sometimes 
been made by careful and competent surgeons. Search for additional 
evidences of the primary cause of infection will frequently furnish valu- 
able information. In gumma of the testicle the presence of other less 
apparent tertiary lesions and the existence of tuberculosis in other 
organs are points upon which the surgeon often rests his diagnosis in 
differentiating between an adenoma and an infective swelling. The 
central part of an infective swelling frequently degenerates and liquefies, 
still further complicating the diagnosis between a cystic adenoma and 
an infective swelling. An exploratory puncture is often of great value 
in ascertaining the character of the contents of a doubtful swelling. 
Primary tuberculosis does not often attack the organs which are the 
favorite seat of adenoma. Tuberculosis of the mammary, thyroid, and 
prostate glands is a comparatively rare affection. Carcinoma of a 
gland differs from adenoma by the absence of any attempts at encap- 
sulation of the tumor and by the presence of regional dissemination 
through the lymphatics. Metastasis never attends adenoma. Cohnheim 
claimed to have found metastasis in a case of adeno-myxoma of the 
thyroid gland. The tumor perforated a vein-wall, and fragments were 
detached and reached the pulmonary vessels, where the secondary 
tumors were found. It is more than probable that in this case, the only 
one of the kind on record, the tumor was malignant, the strongest 
proof of this being the manner in which the tumor reached the lumen 
of the vein. Sarcoma in its earlier stages resembles adenoma, but its 
more rapid growth and the local and often general infection are the 
most important points upon which to base a correct diagnosis. 

Prognosis. — Adenoma without cyst-formation never grows beyond 
certain limits, so that it seldom interferes with important functions by 
its presence. Adeno-cystoma of the ovary often reaches an immense 
size. Adenoma of the middle lobe of the prostate and of the isthmus 
of the thyroid gland of moderate size gives rise to serious symptoms 
of obstruction. With the exception of adenoma of the prostate, gland- 
ular tumors seldom originate in persons advanced in years, and usually 
they become stationary at the age of fifty. Adenoma not infrequently 
undergoes transformation into carcinoma or sarcoma. Malignant 
tumors of the thyroid gland frequently have such an origin. The 
transition into carcinoma is observed oftener than a resulting sarcoma. 

Treatment. — Most of the adenomata can be removed successfully 

by enucleation. In adenoma of the breast the surgeon is often in doubt 

as to whether the tumor is benign or malignant when the operation is 

undertaken. A positive diagnosis can be made after the tumor has 

12 



178 PATHOLOGY AND TREATMENT OF TUMORS. 

been reached. If the tumor is an adenoma, it is supplied with a perfect 
capsule, and can be shelled out from its bed without any difficulty; if it 
is a carcinoma, all evidences at limitation of the growth are absent, the 
tumor infiltrates the surrounding tissues, and the operation is incomplete 
unless the entire breast and all of the axillary glands are removed. If 
any doubt exists in the mind of the operator in cases of glandular 
tumors of the breast, the patient should be informed beforehand that 
conditions might be revealed by the operation which would necessitate 
removal of the entire breast. In the enucleation of benign tumors of 
the breast the incision should be made in the direction of the milk- 
ducts, and the capsule of the gland should be sutured separately after 
the removal of the tumor. 

Adenomata of the uterus and cervix are usually removed by the use 
of the sharp curette. Preliminary rapid dilatation of the cervical canal 
and thorough disinfection of the parts are essential in effecting com- 
plete removal of the diseased tissue and in preventing septic infection. 
Tamponade of the uterine cavity with iodoform gauze and rest in bed 
for at least a week will add to the beneficial effects of the operation and 
will minimize the liability to complications. 

Cystic adenoma of the kidney does not justify nephrectomy, as the 
opposite organ is frequently found similarly affected. If the kidney has 
been exposed by a lumbar incision and the nature of the tumor has 
been determined, enucleation or partial nephrectomy is preferable to 
complete removal of the organ. 

Adenoma of the liver may become an object of operative treatment 
if the abdomen has been opened for the purpose of determining the 
nature of an obscure tumor of that organ. The hemorrhage after 
removal of the tumor by enucleation or excision should be arrested by 
the employment of the aseptic tampon, which is brought out at the 
upper angle of the wound, by the application of the actual cautery, or 
by suturing Glisson's capsule, as advised by Von Bergmann. 



XV. CYSTOMA. 

The term " cystoma" in this book will be used in the most restricted 
histogenetic sense, and will be applied only to those cysts in which both 
cyst-wall and contents are formed anew and independently of pre-existing 
gland-structures. A sharp etiological distinction must be made between 
a cyst, in the ordinary sense in which this word has been used, and 
a cystic tumor or cystoma. The word " cyst " has been used very 
indiscriminately to indicate the existence in a closed cavity of various 
solid and liquid contents. It has been, and is still, used to designate 
the existence of the products of extravasation, inflammation, and re- 
tained secretions in a closed cavity. We shall limit the term " cystoma," 
cystic tumor, to cystic formations in which the cyst-wall is produced 
from a matrix of embryonic cells, and the contents are the products of 
tissue-proliferation of the cells lining the cyst-wall. Used in such a 
limited sense, a cystic tumor is a hollow tumor, the interior of the cyst- 
wall being lined by epithelial or endothelial cells. The cells lining the 
cyst-wall are the essential tumor-cells. Retention-cysts and cysts 
caused by extravasation or inflammation will be excluded from this 
section. The epithelial lining of the cyst-wall is derived either from the 
epiblast or the hypoblast or is composed of endothelial cells. We have 
already described adeno-cystoma and proliferating adeno-cystoma in the 
section on Adenoma. In adeno-cystoma the glandular structure of the 
tumor predominates, the cystic part being accidental and usually limited. 
Proliferating cysts may attain great size, but the glandular part pre- 
dominates permanently. The epithelial cells correspond in shape and 
structure to that part of the epiblast or the hypoblast from which the 
matrix is derived. In cysts representing mucous membrane and ducts 
the cells are usually columnar ; in cysts of epiblastic origin the cells are 
flat, corresponding to the pavement epithelium of the skin (Fig. 92). 
Cysts composed exclusively of mesoblastic tissue are lined by endothe- 
lial cells. Heterotopic cysts are cysts lined with epithelial cells and entirely 
disconnected with tissues or organs of epiblastic or hypoblastic origin. 
Mesoblastic cysts are never heterotopic, as connective tissue can be 
transformed into endothelial cells and endothelial cells into connective 
tissue, and connective tissue is present in the body everywhere. 

179 



i8o 



PATHOLOGY AND TREATMENT OF TUMORS. 



Sterile cysts are cysts in which the epithelial or endothelial lining has 
disappeared by degeneration of its cells (Fig. 92, d). 

Growth of a cyst will continue so long as the cells lining the interior 
of the cyst-wall continue to proliferate. When the cells are destroyed 
by degeneration or otherwise the contents of the cyst cease to increase, 
and the cyst remains stationary or diminishes in size. In Figure 92 
the cystic spaces at b and c, being lined by proliferating epithelial cells, 




Fig 92. — Adeno-cystoma of thyroid gland ; X 50, reduced one-third (Surgical Clinic, Rush Medical 
College, Chicago) : a, stroma ; b, acinus rilled with colloid material and lined by epithelial cells ; c, epithelial 
lining; d, acinus from which all epithelial cells have disappeared, constituting a sterile cyst. 



would increase in size by the addition of new colloid material to the 
contents of the cyst, while the space at d would remain stationary in 
size, because all the epithelial cells have been destroyed by degenera- 
tion, and with the destruction of the epithelial cells the cyst has been 
deprived of any further source of colloid material. The framework of 
the cyst-wall to which the epithelial or endothelial cells are attached 
is composed of connective tissue. The connective tissue in a true 
cystoma is derived from the pre-existing connective tissue, which at 
first is condensed by compression caused by the gradual enlargement 
of the cyst, and later becomes increased in thickness by the production 
of new connective tissue. The cyst-wall may be exceedingly thin and 
delicate if it contains only a small amount of connective tissue, or in 
the course of time it may become enormously thickened by the pro- 
duction of new connective tissue. If the cyst is surrounded by tissue 
on all sides, this tissue gradually becomes more and more isolated 
from the external surface of the cyst-wall, so that finally only the 
vascular connections remain — a condition exceedingly favorable for the 
removal of the cyst by enucleation. The cyst-wall may also become 



CYSTOMA. 181 

firmly attached to the surrounding structures by inflammatory adhe- 
sions, as is so often the case in ovarian cysts and in cysts in other parts 
of the body subjected to partial extirpation or to other inadequate 
methods of treatment. 

The cyst-contents will vary according to the type of the cells which 
produced them. Cysts lined by epiblastic epithelial cells usually 
contain the products of fatty degeneration, an atheromatous material, 
or, if the fatty degeneration has progressed still further, pure oil. 
Cysts lined by columnar epithelial cells analogous to those found 
in the gastro-intestinal canal usually contain mucus. Cysts of the 
thyroid gland contain most frequently colloid material, or, if the col- 
loid material has disappeared by liquefaction, a serous fluid. Meso- 
blastic cysts generally contain a serous fluid. The cyst-contents are 
modified by hemorrhage into the cyst and by the addition of choles- 
terin-crystals — a frequent occurrence, especially in cysts of an epiblastic 
origin. A simple, single cyst is called a monolocular cyst. A cyst in 
which we find different compartments from the beginning, or produced 
later by coalescence of several cyst-walls or by proliferation from the 
cyst-wall, is called a multilocular cyst. The cyst-wall often undergoes 
calcareous degeneration, and sometimes ossification, particularly in cases 
in which the epithelial lining has been destroyed by degeneration. 

Etiology. — Cystoma very frequently appears as a congenital affec- 
tion. The tumor-matrix proliferates during intra-uterine life, and at 
the time of birth the activity of proliferation can be calculated by the 
amount of contents of the cyst. Congenital cystic tumors of the neck 
are of frequent occurrence. Although cystic tumors may occur at any 
time after birth, they are met with most frequently at the age of puberty. 
Sublingual epiblastic tumors make their appearance most frequently at 
this time of life. The great physiological activity of the organs derived 
from the epiblast plays an important part in stimulating a latent matrix 
to active tissue-proliferation, and if this matrix is of such a structure 
or nature that its product is not arranged in glandular form, cystic 
dilatation of its primary central space will follow. The growth of the 
cyst will depend on the amount of essential tumor-elements and the 
activity of their proliferation. Other exciting causes are trauma and 
prolonged irritation and inflammation in the immediate vicinity of the 
tumor-matrix. 

Diagnosis. — A cystic tumor usually grows more rapidly and attains 
a larger size than a papilloma or an adenoma. A central hollow space 
is present from the very beginning, and does not appear later, as is 
the case in adeno-cystoma. If the cyst-wall is not too tense or thick, 
fluctuation can be elicited by careful palpation. If the cyst-wall is thin 



182 PATHOLOGY AND TREATMENT OF TUMORS. 

and near the surface, the tumor is translucent if it contains clear serum. 
In uncomplicated cases of hydrocele of the neck the tumor is trans- 
lucent. An exploratory puncture will often prove of great value, not 
only in showing the cystic nature of the tumor, but also in demon- 
strating the nature of its contents. This diagnostic resource must be 
employed with caution in the examination of abdominal tumors if the 
free peritoneal cavity cannot be avoided. Exploratory puncture through 
the free peritoneal cavity is ordinarily attended by more danger than 
an exploratory incision. In locating the tumor an effort should be 
made to ascertain its primary anatomical starting-point and to bring it 
in connection with the organ in which it originated. If the cyst occu- 
pies the pelvis, it should be ascertained whether it is connected with 
the ovary, the Fallopian tube, or the uterus. If it occupies the abdom- 
inal cavity and is not connected with the pelvic viscera, the relation of 
the tumor to the different abdominal organs must be studied with care 
to determine the organ with which the tumor is connected or to which 
it has become attached. Inflation of the stomach and the intestinal 
canal will often prove an invaluable diagnostic aid in such cases. 

Prognosis. — Cystoma is a benign tumor. A proliferating cyst of 
the ovary may perforate the cyst-wall and invade the peritoneal cavity, 
but aside from this a cystic tumor does not extend beyond the limits 
of the organ primarily affected. Cystoma, if in close contact with im- 
portant organs, may give rise to dangerous complications by causing 
harmful pressure. Cysts of the neck and of the pelvis may become a 
source of danger from pressure. Large cysts of the abdominal cavity 
ultimately interfere with digestion and respiration and become a source 
of danger from their size. Adhesions between pelvic and abdominal 
tumors and the surrounding organs may become a cause of intestinal 
obstruction. Infection of a cystic tumor with pyogenic microbes may 
result in suppuration and sepsis. Torsion of the pedicle of a cystic 
tumor of the pelvis or of the abdomen has often resulted in gangrene, 
septic peritonitis, and death. Malignant transformation is not as often 
observed in cystoma as in papilloma and adenoma. 

Topography. — Cystic tumors are met with most frequently in 
organs and parts of the body in which during intra-uterine life the 
most complicated tissue-changes occur. The favorite localities are the 
ovaries, the base of the tongue, the neck, and the region of the orbits. 

Traumatic Epithelial Cysts. — The accidental or intentional dis- 
placement of a small island of skin into the mesoblastic tissues brings 
about a condition closely resembling the relations of an epiblastic tumor- 
matrix to the surrounding tissues. A few cases have been reported in 
which epithelial cysts had such an origin. The difference between such 



CYSTOMA. 183 

an artificial matrix and a genuine tumor-matrix is the limited prod- 
uct of the epithelial proliferation. Kaufmann studied the behavior of 
attached buried epithelial cells by resorting to a procedure which he 
terms enkatarrlwphy. He selected for this purpose the cock's comb. 
By two elliptical incisions an island of skin was circumscribed ; it was 
then buried by suturing over it the margins of the wound. In some 
of the successful cases the result was followed until the 210th day. 
Examination of the specimens obtained at variable periods after the 
operation showed that at the margins of the buried skin the epithelial 
cells proliferated, resulting in the formation of a cyst-wall lined 
throughout by epithelial cells. The cysts formed in this manner con- 
tained a material which resembled the contents of an atheromatous 



,*v. 









m 






Fig. 93. — Traumatic epithelial cyst of finger (after Garre) : a, skin ; />, subcutaneous tissue ; c, epithelial cyst. 

cyst. The growth of the cysts continued until they reached a certain 
limited size, when it ceased and the cysts remained stationary. 

Garre recently reported two cases of traumatic epithelial cysts of 
the fingers. In both cases the injury which preceded the cyst-forma- 
tion was a punctured wound. The cyst developed soon after the injury. 
In one case the cyst was 12 millimeters in length and 7 to 8 millimeters 
in width. A section through the centre of the tumor showed a central 
cavity (Fig. 93). The implanted fragment of skin could readily be 
identified by its characteristic anatomical structure. The epithelial cells 
at the margins produced new cells which converted the piece of skin 
into a globular mass well supplied with blood-vessels. The cyst con- 
tained exclusively epidermic cells arranged in wavy stratified layers. 
In the other case the cyst had reached the size of a hempseed and 
showed a similar structure. The opinion of Chavasse that such cysts 



184 



PATHOLOGY AND TREATMENT OF TUMORS. 



Fig. 94. — Manner of production of traumatic epithe- 
lial cyst (after Garre) : a, skin ; b, subcutaneous tissue ; 
c, dislocated fragment of skin. 



W^Sm-'i; ,*•-. ■--"-/ 




are produced by the sweat-glands contained in the implanted skin is 
contradicted by Garre. The process of cyst-formation as explained by 
Garre can readily be understood by a glance at Figures 94, 95, and 
96. He did not find any evidences of the formation of a cyst-wall as 
described by Kaufmann. 

Reverdin believes that epithelial cysts can originate from the dis- 
placement of detached mature epithelial cells into the mesoblastic 

tissues. Garre's second case was 

one 111 point. In this case only 
: ':'V>^"; ; ~~;i ' ■/'--- ; cells were forced into the subcu- 
':>,;■'.- S-^ --,;.. <- taneous tissue before the point 
--J^y-CvljC-- of a needle, and from them a 
globular mass of epithelial cells 
developed, but no trace of a 
cyst-wall could be found. Rizet 
reported a case in which the 
epithelial cells that originated 
from a displaced fragment of skin 
became the seat of a calcareous 
degeneration. In other instances 
the cells have frequently been 
eliminated by suppurative inflam- 
mation. 

Tatum observed on the scar of 
a scalp wound an atheroma-cyst 
which undoubtedly was caused 
by a dislocated particle of skin. 
A conclusion of the greatest eti- 
ological moment that can be 
drawn from the experiments of 
Kaufmann and the clinical ob- 
servations of Garre and others 
is this, that a dislocated fragment of skin does not possess the same 
intrinsic capacity of continued progressive tissue-proliferation as an epi- 
blastic tumor-matrix. Epithelial cysts of a similar origin are found 
more frequently in the scars following burns than after trauma. Epi- 
thelial pearls in scar-tissue, the product of buried epithelial cells, are 
not of rare occurrence. Traumatic epithelial cysts must be removed 
by thorough extirpation, otherwise a recurrence will almost surely take 
place. 

Deep-seated Atheroma. — A retention-cyst of the sebaceous glands 
resembles a true atheroma so perfectly in the structure of the cyst-wall 



Fig. 95.— Beginning of healing of the skin-defect 
and commencing proliferation from the margins of the 
implanted skin (after Garre). 




Fig. 96.— Wound entirely healed, and the buried 
skin-graft enlarged by proliferation from the surface 
and margins of the graft (after Garre). 



CYSTOMA. 185 

and in its contents that we must distinguish between them etiologically 
and clinically according to their location. Retention-cysts of the seba- 
ceous glands result from obstruction to the escape of the secretions, 
and always retain their relations with the skin. They are superficial, 
being covered only by the skin. The deep-seated atheroma has no con- 
nection with the glandular apparatus of the skin, and it always originates 
from a displaced matrix of embryonic cpiblastic cells. It should be dis- 
tinguished from a dermoid cyst by the character of its contents. An 
atheroma contains only epithelial cells as its characteristic morphologi- 
cal cellular element, while the cyst-wall of a dermoid cyst represents 
skin with its appendages in the simplest cases, and in more complicated 
cases systems of organs in various degrees of perfection. The displace- 
ment of the matrix of an atheroma occurred at a time prior to the differ- 
entiation of the cpiblastic cells into the organs representing the appendages 
of the skin, while the matrix of a dermoid cyst points to a later displace- 
ment of the matrix. Atheroma is met with most frequently in the 
ovaries, in the region of the orbits, especially the superciliary arch, and 
at the base of the tongue. In all these localities it is most frequent 
at the age of puberty. In the superciliary region it occurs occasion- 
ally as a congenital affection. In this locality it seldom exceeds 
the size of a walnut, while tumors at the base of the tongue the size 
of a cocoanut are not uncommon. Superciliary atheromata frequently 
contain pure oil which will ignite and burn like ordinary lamp-oil. 
When this stage of degeneration is reached further growth is generally 
arrested. In the majority of cases the tumor contains a substance 
resembling in every respect the contents of a retention-cyst of the 
sebaceous glands. The granular detritus is composed of epithelial cells 
which have undergone fatty degeneration suspended in a serous fluid 
in varying proportions. Cholesterin-crystals are often very abundant 
in old cysts. Cysts at the base of the tongue project toward the cavity 
of the mouth, and when they have reached a certain size they form a 
swelling in the submaxillary region, causing great disfigurement, and 
by pressure against the tongue interfering with speech and often also 
with deglutition. The differential diagnosis between such a tumor and 
a branchial cyst is often difficult, and sometimes can be made only by 
resorting to an exploratory puncture. A branchial cyst usually con- 
tains either mucus or a serous fluid ; an atheroma contains the product 
of fatty degeneration of epithelial cells. 

An atheroma may occur in almost any part of the body, and in the 
differential diagnosis of cysts in unusual localities this fact should be 
taken into consideration. The cyst-wall of an uncomplicated atheroma 
is loosely attached, and can readily be removed by enucleation. 



1 86 



PATIJOLOCV AND TREATMENT ()/< TUMORS. 



Mucous Cysts. — Cystic tumors with mucoid contents arc compara- 
tively rare if we exclude from this category retention-cysts with similar 
contents. They are analogous to atheroma in their etiology, except 
that the matrices art: derived from the hypoblast and that the interior of 
the cyst-wall is lined by columnar epithelium. In place of atheroma- 
tous material the cysts contain mucus, which in old cysts is usually 
transformed in the course of time into a serous fluid. Jf the cyst is 
derived from a matrix representing squamous or ciliated epithelia, it 
is lined by cells representing the part or organ from which the epi- 
blastic or hypoblastic matrix was derived. Frequent locations of these 
cysts are the orifice of the cervical canal of the uterus and the mucous 

membrane of the lips, mouth, phar- 
ynx, and intestinal canal. Mucous 
cysts seldom attain the size of a 
walnut, as, owing to the delicate- 
structure of the cyst-wall, rupture 
takes place- usually before the tu- 
mor reaches this size. Tin- epithe- 
lial cells are generally arranged in 
a single layer, and are not stratified 
as in cpiblastic epithelial cysts — an 
additional cause for (he early rup- 
ture of these cysts that so fre- 
quently takes place. Many of the 
so-called "hydatid" cysts are mu- 
cous cysts, the mucoid substance 
having become transformed into a 
transparent serous fluid. Among 
the morphological elements in the 
contents of a mucous cyst are epi- 
thelial cells, free nuclei, cholesterin- 
crystals, colloid masses, and sometimes concretions. The mucous cysts 
are usually globular in shape; owing to the fragility of the cyst-wall, 
they seldom become pedunculated. K.xtirpation and the complete- 
destruction of the epithelial lining of the cyst by cauterization are the 
only two operative procedures which can be relied upon in preventing 
a recurrence-. With very few exceptions, enucleation is impractical, 
owing to the great fragility of the cyst-wall. 

Cysts lined by ciliated epithelial cells always have their origin from 
an embryonic matrix derived from parts and organs supplied with 
ciliated epithelium in the fetal state. Cysts of this kind have been 
found in the brain, the external ear, the liver, and the testicles. 




ong'.-nital 



rvir.; ( | cyst ':xt-:n<Ji J 



tl,« axill.-r Cfl.jrT. Smith). 



CYSTOMA. 187 

Mesoblastic Cysts. — Cysts composed exclusively of tissue of meso- 
blastic origin arc found most frequently in the region of the neck, where 
they have been described by the German authors as " hygroma " and 
by the English surgeons as " hydrocele of the neck." This form of 
cyst is always of congenital origin ; it occupies the deep tissues of the 
neck in front of the large vessels, and often extends from the hyoid 
bone down to the clavicle and even as far as the axillary space (Fig. 
97). Congenital cysts of the neck often shrivel soon after birth and 
disappear spontaneously; at other times they increase rapidly in size. 
In a few instances they reappeared later in life, such a case being 
reported by Birkett. They are usually unilocular, but sometimes 
they are divided in part or completely into a number of compart- 
ments with similar contents. If the cyst is large and contains a 
clear serous fluid, it is translucent. The histology of these cysts has 
not been investigated sufficiently. The very fact that in the majority 
of cases they disappear spontaneously is sufficient proof that epi- 
thelial cells do not enter into their construction. Some authors have 
suggested that these spaces are ectatic lymph-spaces. If the cyst per- 
sists, the wall of the space would be sure to become lined by endothe- 
lial cells, as under such circumstances the connective-tissue cells on the 
surface would become transformed into endothelial cells. Such trans- 
formation of connective-tissue cells into endothelial cells is frequently 
observed in the formation of accidental bursa; and in the formation of 
false joints in ununited fracture. The attempt to remove such cysts 
by extirpation is attended by danger, and often has to be abandoned 
before the completion of the operation. The injection of irritating 
solutions has also been followed by disastrous consequences. Repeated 
evacuation by tapping, followed by the injection of a 5 per cent, solu- 
tion of carbolic acid under strictest antiseptic precautions, is the safest 
and most efficient method of treatment. Cysts developing from an 
embryonic mesoblastic matrix after birth are formed in the same way 
as epithelial cysts. The central space in the matrix becomes lined by 
endothelial cells ; serous contents accumulate and distend the space. 
The spontaneous disappearance of endothelial cysts is of frequent 
occurrence, as the endothelial cells may at any time revert into their 
former condition, and the cyst-contents are more amenable to absorp- 
tion than are the products of epithelial cells. If the cyst is emptied by 
absorption of its contents and the endothelial cells lining the cyst-wall 
are brought in contact, permanent obliteration of the space will follow. 

Thyroid Gland. — A true cyst of the thyroid gland commences as 
such. The formation of the cyst is not preceded by any considerable 
production of glandular tissue. The glandular tissue is scant}-. In 



1 88 PATHOLOGY AND TREATMENT OF TUMORS. 

cystic degeneration of an adenoma of the thyroid gland cyst-formation 
takes place usually at different points, and the glandular part of the 
tumor predominates (Fig. 98). The cysts enlarge by the breaking 
down of the thin compartments between smaller cysts, and the cystic 
nature of the tumor becomes clinically apparent only after the larger 
part of the glandular structure has been destroyed by degeneration. 
In a true cystoma the cavity is formed by expansion of the epithelial 
cells from a central point of the tumor-matrix, and the tumor is more 




Fig. 98— Adenocystoma of thyroid gland; X 85 (Surgical Clinic, Rush Medical College, Chicago): 
a, a, stroma; b, follicles of gland slightly enlarged ; c, colloid cyst ; rf, two colloid cysts separated by a thin 
septum. 

frequently unilocular than multilocular. Of course, a number of cysts 
may form simultaneously and coalesce into one common cavity, but 
this occurrence is rare as compared with adeno-cystoma. A cystoma 
of the thyroid gland can usually be recognized without difficulty, but 
if any doubt exists, this can be set aside effectually by an exploratory 
puncture. Enucleation is the proper treatment for cystic tumor of the 
thyroid. If this operation cannot be done on account either of calcareous 
degeneration of the cyst-wall or of firm adhesions with the surround- 
ing tissues, a partial thyroidectomy is indicated. Laying open of the 
cyst freely by incision, followed by vigorous application of the actual 



CYSTOMA. 189 

cautery so as thoroughly to destroy the cellular lining of the interior 
of the cyst-wall, will also effect a radical cure, but this treatment 
consumes more time and will leave a more unsightly scar than either 
enucleation or extirpation. 

The writer has recently treated successfully a cyst of the thyroid 
gland the size of a hen's egg by a single tapping, followed by the 
injection of 2 drams of a 10 per cent, emulsion of iodoform in 
glycerin. 

Mammary Gland. — Retention-cysts and adenocystoma of the mam- 
mary gland occur much more frequently than true cysts. In both 
instances the cysts are frequently multiple, and seldom do they attain 
great size. Bryant divides cysts of the mammary gland into three 
varieties : 1. Cystic degenerations of the breast, met with in the aged as 
well as in glands which have long ceased to be active — " involution- 
cysts," as they are called ; 2. Cystic tumors of the gland, single or 
multiple, of glandular, duct-, or connective-tissue formation, without 
intracystic growths ; 3. Cystic tumors of the breast, of whatever kind, 
in which papillomatous, adenomatous, sarcomatous, or carcinomatous 
intracystic growths are present. 

A true cystic tumor commences, like all true cystomata, in the centre 
of a matrix of embryonic epithelial cells, the epithelial cells becoming 
attached to the surrounding connective tissue, which becomes the 
stroma of the tumor. The products of epithelial proliferation accumu- 
late in the central space and form the contents of the cyst. Serum, or 
serum altered by the presence of blood or cholesterin-crystals, is usu- 
ally found as the characteristic contents of such a cyst. The tumor 
grows slowly in size, displaces the surrounding tissues, and often 
reaches an enormous size. Paget refers to a case in which the tumor 
contained nine pounds of serous fluid. He remarks, very correctly, 
that tumors which contain the simplest fluids and which have the 
simplest walls are apt to grow to the largest size. Thickening of cyst- 
walls and, much more, their calcification are here, as elsewhere, signs 
of degeneracy and of loss of productive power. A true cystoma of 
the mammary gland is characterized clinically by its progressive growth, 
its simple contents, and the thinness of the cyst-wall. 

Another form of cyst of the mammary gland is described as " pro- 
liferous cyst," in which, from the cyst-wall, papillary excrescences 
project into the cyst, resembling the same kind of cyst in the ovary. 
This kind of cyst, however, more frequently occurs associated with 
adenoma or sarcoma of the breast than as a distinct anatomical variety 
of cystoma. 

Enucleation is the proper treatment of cystic tumors of the breast ; 



190 



PATHOLOGY AND TREATMENT OF TUMORS. 



if this operation does not succeed on account of firm adhesions or of 
degeneration of the cyst-wall, the excision of a small zone of gland- 
tissue with the cyst will ensure a radical cure. 

Ovary. — As cysts of the ovary have so many different histogenetic 
sources from which they take their origin, and as the different localities 
correspond with so many structures of different embryonic origin, the 
student must familiarize himself with the development of the ovary in 
the embryo in order to enable him to trace the different kinds of cysts 
to their proper embryonic matrices (Fig. 99). 




Fig. 99. — Scleroma of tubo-ovarian apparatus, to show the various points of origin of cystic growths 
(after Doran) : aa, multilocular glandular cyst, developed in a, ovarian parenchyma ; c, papillary cyst, devel- 
oped in b, tissue of the hilum of the ovary ; d, unilocular cyst of the broad ligament, free from the parova- 
rium, k; e, unilocular cyst of the broad ligament, situated just above the Fallopian tube, but not united to 
it; f, similar cyst near^, utero-ovarian ligament ; /:, hydatid of Morgagni, which is never the starting-point 
of a large cyst; i, cyst developed at the expense of the horizontal canal of the parovarium; /, cyst devel- 
oped at the expense of the vertical tube (according to Doran, these are the papillary cysts of the broad liga- 
ment) ; m f n, course of the obliterated canal of Gartner ; papillary cysts may be developed at any portion 
of this canal (Coblenz), and these cysts may be the origin of papillary cysts connected with the uterus, n. 

The size of the cyst will depend on the vegetative capacity of the cells 
of the tumor-matrix. The nature of the contents of ovarian cysts is 
determined by the histological character of the tumor-cells and by the 
type of degenerative changes which these cells undergo. The hydatids 
of Morgagni consist of an exceedingly delicate cell-wall and a trans- 
parent clear serum as contents, and they seldom exceed the size of an 
ordinary marble. They are usually pedunculated, and are discovered 
only in opening the abdomen for other indications. 

The multiple cysts with serous contents that characterize the cystic 
ovary as described by Rokitansky hardly ever exceed in size a cherry- 
stone (Fig. 100). 

Ovarian cysts of this variety are always complicated by sclerosis 
of the interstitial tissue. In a very instructive paper on ovarian papillo- 
ma Coblenz gives an accurate histogenetic account of this variety of 



CYSTOMA. 191 

ovarian cysts. The author comes to the conclusion that the Pfliiger- 




Fig. 100. — Cystic disease of the ovaries : serous and myxomatous multiple follicular cysts (after Pozzi) : 
a, a', small myxomatous cysts ; b, b' , large myxomatous cysts ; e, e', follicular cysts with fluid contents ; c, 
g, g* , follicular cysts with caseous contents ; o,f,/', ovarian tissue containing small follicular cysts. 

Waldeyer epithelial sacs, as well as the medullary tubules of Kolliker, 
may give rise to the formation of cysts, but that from the former the 




Fig. 101.— Papillary cyst starting from the hilus of the ovary (aftor Doran). On the left lower extreme 
of the picture is the ovary, which is almost intact. The cyst is developed within the broad ligament, which 
is opened so that we may see above a portion of the Fallopian tube. An opening has been made in the cyst- 
wall to show the papillary vegetations within. 

glandular, and from the latter the papillary, variety are produced. At 



192 



PATHOLOGY AND TREATMENT OF TUMORS. 



any rate, the papillary cysts are genetically and anatomically analogous 
to the papillary formation of the mucous membranes, whether they are 
in the interior of cysts or whether they spring from the surface of the 
ovary. In the latter case the tumor may have developed from the sur- 
face of the ovary or may have reached this locality from the interior of 
a cyst. Proliferous cysts spring either from the surface of the ovary 
or from rests of fetal tubules in the ovary (Fig. 101). The cystic spaces 
are usually small, and the proliferating masses in their interior are large. 
Papillary growths on the surface of the ovary, and similar vegeta- 
tions reaching the surface after perforation of a proliferous cyst, spread 




Fig. 102. — Papillary tumor of ovary covering the whole of both broad ligaments (after Pozzi). 



to the surrounding parts, often imbedding ovary, tube, ligament, and 
uterus (Fig. 102). The histological structure of a papuliferous tumor 
of the ovary is well shown in Figure 103. 

Proliferous cysts of the ovary are more likely to return after opera- 
tion than are any of the other benign tumors. If the tumor develops 
from the surface of the ovary, or if the operation is postponed after a 
proliferous cyst has been perforated, fragments of the tumor frequently 
remain, and it is from these fragments that the recurrence takes place. 
Recurring tumors have no pedicle and are usually extensively adherent, 
rendering their removal difficult and sometimes impossible. If the 
tumor-tissue comes in contact with the peritoneal surface, ascites sets 
in, still further complicating the case. 

Glandular cysts of the ovary always occur as a multiple affection 
(Fig. 104). By breaking down of the septa the cavities enlarge (Fig. 
105). The contents undergo various regressive changes and vary 
greatly in different cysts of the same tumor. Some cysts contain a 
jelly-like, amorphous mass, others a clear serum, and still others a 
serous fluid stained by the admixture of blood. 



CYSTOMA, 




194 PATHOLOGY AND TREATMENT OF TUMORS. 

The origin of simple cysts of the ovary has been the subject of care- 
ful investigation, but has not definitely been settled. The so-called "fol- 
licular cysts " are dilated Graafian follicles. All the histological elements 




Fig. 105. — Adenocystoma of right ovary (after Winckel). In the anterior wall of the large cyst a number 
of small prominences indicate the location of smaller cysts. 

of a normal follicle are found in such cysts. The cysts are numerous 
and are separated by septa of connective tissue (Fig. 106). The spaces 
are lined by columnar epithelium, and ova have been found in their 




Fig. 106. — Follicular cysts of ovary (after Barnes). 



interior by Ritchie, Webb, Tait, and Rokitansky. The cysts contain 
usually clear serum ; occasionally the serum is of a yellowish color, 
and sometimes it is otherwise stained by the admixture of blood. 



CYSTOMA. 



19 



Sometimes the epithelial cells undergo myxomatous degeneratio: 
(Fig. 107). 

Hydrops of the follicles of the ovary is usually a symmetrical affec 
tion occurring in both ovaries at the same time. Follicular cysts of th 
ovary seldom result in the formation of large tumors. It was former! 
believed that most of the simple ovarian tumors resulted from disten 
tion of pre-existing Graafian follicles by proliferation of the epithelia 
lining. That this is not the case is now generally admitted, but tha 
occasionally an ovarian cyst may have such an origin cannot be deniec 




If in a Graafian follicle a matrix of embryonic epithelial cells shoulc 
exist, we can readily understand that the follicle would become the 
cyst-wall, while the matrix would furnish the contents. Neumann ex- 
amined a monolocular ovarian cyst which contained four liters of fluid, 
and found that the cyst had developed from a Graafian follicle. The 
deposit which formed in the fluid after standing for some time contained 
epithelial cells of the membrana granulosa and innumerable ova with 
a distinct zona pellucida. Neumann estimated the number of ova at 
many thousands. The majority of simple ovarian cysts undoubtedly 
originate from embryonic tubular rests. 



196 



PATHOLOGY AND TREATMENT OF TUMORS. 



Cysts of the corpus luteum were ascribed by Rokitansky to preg- 
nancy, but Gottschalk found them also in nullipara. The contents of a 




— Corpus luteum ; X 350. 



corpus luteum of the ovary without cystic degeneration are shown in 
Figure 108, which shows the epithelial cells of the follicle and rem- 
nants of the blood-clot. Cystic degeneration of a 
follicle may lead to the formation of cysts as large 
as an apple. Nagel has seen them as large as an 
adult's head. Cysts of the corpus luteum (Figs. 
109, no), as well as follicular cysts, are not cystic 
tumors, but are retention-cysts. 

The parovarium (Fig. 99, k) is frequently the 
seat of cyst-formation. This structure is an em- 
bryonic remnant, and consequently it frequently 
contains the essential tumor-matrix. Cysts of the 
parovarium (Fig. in) are also called "cysts of 
Rosenmuller's organ," because their origin in the broad ligament, in 
which they are situated, corresponds to the seat of these embryonic 
remains. Verneuil, Doran, and De Sinety believe that these cysts are 
developed in the connective tissue independently of the parovarium. 




Fig. 109. — Cyst of the 
corpus luteum; natural size 
(after Nagel). 



CYSTOMA. 



197 



Supernumerary ovaries must also be remembered as a possible source 
of such cysts. 

According to the structure of the cyst-wall and the character of 



¥: b - „/, ,. 




Fig. iio. — Cyst of the corpus luteum ; X 50 (after Nagel) : a, connective tissue of the internal surface, 
epithelium removed ; b, yellow layer of corpus luteum ; c, normal tissue of the ovary near the hilum. 

the contents, cysts originating from the parovarium or in its immediate 
vicinity are divided into — i. Hyaline cysts ; 2. Papillary cysts ; 3. Der- 
moid cysts. Cysts developing from this locality do not reach a large 




Fig. hi.— Unilocular parovarian cyst of the broad 
ligament (after Doran). To the left and above is the 
incised ovary, which is seen to be free. The elongated 
Fallopian tube is spread over the surface of the cyst. 




Fig. 112. — Morgagni's hydatid (after Winckel). 



size, and they contain a serous fluid. Their removal is attended by 
difficulty, owing to the absence of a pedicle. 

Morgagni's hydatids (Fig. 112) are small, translucent, pedunculated 



198 



PATHOLOGY AND TREATMENT OF TUMORS. 



1 



cysts attached to the fimbriated extremity of the Fallopian tubes. 
According to Waldeyer, these cysts are caused by partial distraction 
of Muller's canal by fixation of a part of this structure to the diaphrag- 
matic band of the primary kidney. These cysts are perfectly harmless, 
and never exceed in size a hazelnut. 

Intraligamentous cysts of the broad ligament often attain the size 
of a fetal head, contain a clear serous fluid, and are lined by squamous, 
ciliated, or columnar epithelial cells, according to the origin of the 
tumor-matrix. In diagnosis they are often mistaken for ovarian cysts 
and for the different varieties of retention-cysts of the Fallopian tube. 

Their removal by enucleation is one 
of the most difficult of all pelvic 
operations. Tapping these cysts is 
not attended by much risk, and the 
operation has occasionally resulted 
in a permanent cure. 
Jll*"" ^/% " J k Treatment. — The proper treatment 

of an ovarian cyst, irrespective of 
its origin and size, is removal by 
abdominal section. If no contrain- 
dications exist, the operation should 
be performed as soon as the diag- 
nosis can be made. Under strict 
antiseptic precautions the abdomen 
is opened to the requisite extent 
through the linea alba. After re- 
moval of the contents of the cyst 
by tapping the tumor is drawn for- 
ward into the wound and its pedicle 
is ligated after transfixion by a double 
ligature of silk, and the cyst is sev- 
ered at a safe distance from the liga- 
tures, in order to prevent hemorrhage from slipping of the ligatures. 
The stump should be dusted lightly with iodoform, after which it is 
returned into the abdomen and the external incision is closed in the 
usual manner. If the adhesions are firm, it is advisable to leave the 
peritoneal covering attached to the adherent organs to prevent visceral 
injuries. In aseptic cases drainage may usually be dispensed with 
unless made necessary by hemorrhage, when a Mikulicz drain should 
be employed. In closing the abdominal incision the peritoneum and 
the fascia of recti muscles should be sutured separately. The silk-worm 
gut should embrace all tissues except peritoneum. 




Fig. 113. — Anterior portion of a cow's vagina, 
showing two large cysts developed in the terminal 
segment of Gartner's duct (after Sutton). 



CYSTOMA. 199 

Vagina. — Vaginal cysts, except those resulting from retention of 
secretions, arise from embryonic remnants of the distal part of Gartner's 
duct (Fig. 1 13). The writer has removed two such cysts, as large as a 
hen's egg, filled with mucus. These cysts are lined with stratified epi- 
thelium. Their enucleation from the vagina is not attended by any 
special difficulty. 

Testicle. — Cysts of the testicle were described by Astley Cooper as 
" hydatids," and Curling included them under the general term "cystic 
disease of the testis." Cystic tumors of the testicle are cysts which are 
developed independently of pre-existing glandular structures, in con- 
tradistinction to spermatocele, which forms in consequence of a 
mechanical obstruction interfering with the escape of the physiological 
secretion of this organ. From the category of cystoma of the tes- 
ticle must also be excluded the different varieties of hydrocele. The 
Wolffian body enters largely into the composition of the testicle, anc 
is without doubt the source of many cystic formations ; simple exam- 
ples are the cysts of the organ of Giraldes. The hydatids of Mor- 
gagni and other rests of Miiller's duct are possible starting-points 
of cysts. The cyst-wall is composed of an abundant new growtr 
of connective tissue lined by columnar, ciliated, or rarely by strati- 
fied epithelium. How far the simple stratified cysts are derivec 
from adult spermatic tubes, how far from spermatic tube-rests which 
have failed to unite with Wolffian-duct tubes, it would be difficult tc 
decide. That some of the sperm-containing cysts owe their origin tc 
these rests seems veiy probable ; indeed, Paget suggested that in these 
cysts spermatozoa were secreted by the lining membrane. Not long 
ago the writer removed a cystoma of the testicle, and found in the 
contents of the cyst numerous spermatozoa and a few epithelial cells 
The tumor was perfectly encapsulated, with no connection whatevei 
with the glandular apparatus of the testicle, and was enucleated witl 
ease. Occasionally, cystic tumors of the testicle are multilocular. 

Enucleation is the proper treatment. During the operation th< 
same precautions must be observed as in the removal of adenomat; 
of this organ, to prevent injury to the spermatic cord or the testicle 
After enucleation the visceral layer of the tunica vaginalis should b< 
sutured by a buried row of catgut sutures. 

Eye. — The iris and the cornea are the most common localities ol 
cysts of the eyeball. In the iris they occur most frequently upon th< 
anterior surface as sessile or pedunculated cysts containing a serou: 
fluid or a sebaceous material. Mr. Hulke collected 21 cases of cyst: 
of the iris, and found that in 17 cases the cyst-formation was pre 
ceded by an injury. He suggests that some of these cysts originatec 



200 



PATHOLOGY AND TREATMENT OF TUMORS. 



from portions of Descemet's membrane that may have been torn from 
the cornea and implanted on the iris. 

Corneal cysts (Figs. 1 14, 1 1 5) are caused most frequently by implanta- 
tion of corneal tissue resulting from 
operations or injuries. This cause 
of cyst-formation has been studied 
carefully by Treacher Collins. 





Fig. 114.— Large implantation-cyst of the cor- 
nea following an injury (after Collins). 



Fig. 115. — Section of the cyst in Figure 114 
{highly magnified), showing the laminated epithelium 
(after Collins). 



Lung diverticulum 



The cysts of the cornea following an injury are produced in the 
same manner as the traumatic epithelial cysts described in the begin- 
ning of this section. They arise from transplantation of conjunctival 

epithelium into the deep tissues of the 
cornea. 

Cysts of the Vitello-intestinal Duct. 
— The profession is greatly indebted to 
J. Bland Sutton for a more thorough 
understanding of cysts of the vitello- 
intestinal duct and cysts of the urachus. 
His investigations have done the most 
toward enabling surgeons to refer hith- 
erto obscure cysts in these localities to 
their origin from remnants of embry- 
onic life. Cysts of the vitello-intestinal 
duct (Fig. 1 16) connected with the um- 
bilicus of babes and young children, 
and varying in size from a pea to a 
cheny, are of frequent occurrence. 
They are usually pedunculated, and are 
composed of unstriped muscle-fibre, 
mucous membrane, Lieberkuhn's folli- 
cles, and columnar epithelium collected 
in a mass. These cysts may enlarge, 
rupture spontaneously, and leave a sinus from which escapes a watery 




Vitello-intestinal 
duct. 



Fig. 116. — Diagram of the alimentary 
canal of the embryo, showing the position 
of the yolk-sac (after Sutton). 



CYSTOMA. 201 

discharge. In rare cases that part of the vitello-intestinal duct con- 
nected with the ileum becomes the seat of cyst-formation. Such a 
case was reported by Roth. Occasionally the entire duct remains 
patent, when part of the intestinal contents escape from its opening at 
the umbilicus. Sutton has traced imperforate ileum to the vitello- 
intestinal duct. 

Allantoic (Urachus) Cysts.— The urinary bladder of man presents 
at its apex an impervious cord, known as the urachus, which passes to 
the umbilicus. The duct is obliterated at birth, and in the adult lies in 
the subperitoneal tissue in the middle line of the anterior abdominal 
wall. If the urachus does not become obliterated in any part of its 
course, it becomes dilated, and the cyst is found outside the peritoneum 
and in close relation with the bladder. The whole of the intra-abdom- 
inal part of the urachus may remain patent and form a large urinary 
bladder. Shattock observed such a case. If the entire urachus remains 
open, urine escapes at the umbilicus. Tait reported a case in which he 
found a large cyst of the urachus beneath the abdominal wall. The 
surgical treatment of such cases is not well settled, and must be deter- 
mined largely by the size and location of the cyst. 

Cysts of the vitello-intestinal duct and the urachus are not cysto- 
mata, but are retention-cysts resulting from faulty development. 

Bone. — True cystoma of bone is exceedingly rare. Engel describes 
the case of a female fifty-five years of age, the mother of six healthy 
children, who died of an acute affection and who had never exhibited 
symptoms indicative of any bone-lesion. At the post-mortem the 
entire skeleton was found occupied by cysts varying in size from that 
of a pea to three inches in diameter. The cysts contained a clear or a 
bloody serum. The cyst-walls consisted of a layer of connective tissue. 
In a few cases isolated cysts of considerable size have been found in 
different bones. 

Bone-cysts developing from a displaced matrix of embryonic epithe- 
lial cells are most frequently met with in the maxillary bones. 

Single cysts of the jaws are usually developed in connection with 
displaced or diseased teeth, and consequently are met with most fre- 
quently in young persons. 

Multilocular cysts of the jaws (Fig. 117) are a great rarity. Re- 
cently two such cases from the clinic at Bonn were described by Becker. 
This author found in literature sixteen additional cases. The lower 
jaw is more frequently the seat of this tumor. From this fact alone 
it is evident that displaced dental germs are not the cause of these 
cysts, as most authors claim. In the upper jaw such cysts may rup- 
ture into the antrum of Highmore. They are found more frequently 



202 PATHOLOGY AND TREATMENT OF TUMORS. 

m the region of the molar and bicuspid than in that of the other teeth. 
The youngest patient was twelve years, the oldest seventy-two years 
of age. The growth, which commences during childhood and puberty, 
is slow. Trauma and inflammatory affections are the exciting causes. 
According to the location of the matrix the cyst will project either 
from the outer or the inner side of the jaw. 

The crackling sensation {bruit de parchcmin) as a diagnostic sign 



/V^I'-./V*. -■I 













V-'o'^'^lp'-*- 







Fig. 117. — Multilocular cystoma of the lower jaw; vertical section through tumor, X 176 (after Becker): 
C, cylindrical cells ; P, polygonal cells ; Pi, flattened polygonal cells ; 5, stellate cells ; V, vacuoles ; Cy, cyst ; 
Pk, pearl-globe (Kugel) ; A' granular contents of cyst ; Ca, capillary from stroma into alveolus ; Ck, colloid 
mass ; St, stroma. 

in the examination of multilocular tumors of the jaw was described by 
Runge in 1775, and later by Dupuytren. Fluctuation appears when the 
bony wall has been absorbed, and is consequently a later sign. Ulcer- 
ation of the gums does not take place. Such tumors often attain an 
enormous size. Falkson and Bryk describe a case in which the tumor 



CYSTOMA. 203 

weighed one and a half kilograms and reached from the zygomatic arch 
to the sternum. On section through the tumor a system of hollow spaces 
was disclosed. Some of the cysts communicated with others. The 
septa are usually membranous. These cysts contain a viscid fluid some- 
times mixed with blood. The size of the cysts varies from minute 
spaces to that of a hen's egg. The inner surface of the cysts is smooth. 
In the study of these cysts three stages are apparent : 1. Cellular cords ; 
2. Alveoli ; 3. Cysts. 



XVI. CARCINOMA. 

The subject of carcinoma is one of immense etiological and clinical 
interest. The etiology has been investigated and discussed for cen- 
turies, and, although great progress has been made in tracing the histo- 
genetic origin of carcinoma to its proper source, the explanation of the 
real cause awaits discovery. The etiology has recently received renewed 
interest from the bacteriological researches that have been made to prove 
the microbic origin of carcinoma. As we shall see farther on, no posi- 
tive proof has been furnished so far that carcinoma is a microbic disease. 
The clinical interest of carcinoma arises from the prevalence of this 
affection and the inadequacy of the present surgical resources to cope 
with it successfully. To what fearful extent carcinoma figures as a cause 
of death can be learned from the fact that in England and Wales during 
ten years (1860-1870), 2,379,622 persons above the age of twenty died, 
and that this number includes 81,699 deaths from carcinoma, the deaths 
from this cause constituting to all others a ratio of 1 : 29. There can 
be but little doubt that this disease is on the increase. The dread of 
carcinoma is almost universal. Its terrors have been described in prose 
and in poetry. Shakespeare alludes to it in Hamlet: "And is't not to 
be damned, to let this canker of our nature come in further evil?" 
Not only the profession, but also the public, is aware of the great 
shortcomings of surgery in its treatment. The impression prevails 
among the people that it is incurable. The great mass of the people 
have abandoned all hope of the receipt of permanent benefit from the 
recognized surgical craft for this affection, and seek aid from so-called 
" cancer specialists " that exist everywhere and fatten on the credulity 
of an army of despondent, almost desperate, cancer patients. This sad 
condition of affairs, and with it the remunerative occupation of this 
horde of pretenders, will cease to exist when the discovery of the real 
cause of carcinoma is made and when successful therapeutic measures 
are established upon such basis. The writer has great confidence in 
future investigations in this direction. A great number of tireless, 
honest investigators are at work, and the prophesied results will be 
realized in time. 

Definition. — Carcinoma is an atypical proliferation of epithelial cells 
from a matrix of embryonic cells of congenital or post-natal origin. 

204 



CARCINOMA. 205 

This definition includes what is known of the histogenetic origin of 
carcinoma. It refers the tumor to its primary location in mesoblastic 
tissue, and the origin of its cellular elements to a matrix of embryonic 
epithelial cells. The heterotopic location of the epithelial cells distin- 
guishes carcinoma from all the benign epithelial tumors. Atypical pro- 
liferation of epithelial cells means their growth and multiplication in 
a locality where epithelial cells have no legitimate citizenship. The 
matrix may occupy such a location from the very beginning when 
embryonic cells have been displaced into mesoblastic tissue during the 
development of the embryo in the case of congenital matrices ; or 
when in a burn or a wound or an inflammatory process embryonic cells 
become buried in the mesoblast after destruction of the membrana 
propria in matrices of post-natal origin ; or, finally, if the matrix is 
confined to the epiblastic or hypoblastic tissues, the carcinoma dates 
back to the time when the embryonic cells passed through and beyond 
the membrana propria into the vascular mesoblastic tissues. 

Views Past and Present regarding- the Origin and Nature of 
Carcinoma. — The old authors were familiar with the gross appearances 
and the clinical aspects of carcinoma. The division into open and sub- 
cutaneous carcinoma was made at an early day ; the former was de- 
scribed as cancer apcrtus, and the latter as cancer occulttts. Celsus 
understood under the term " cancer " the several forms of gangrene. 
Galen insisted on an early diagnosis, which he based almost exclusively 
upon its clinical course. yEtius gave an accurate description of carci- 
noma of the uterus. The classical description of cancer by Soranus 
would be no discredit to a modern work on general pathology. All 
malignant growths were included under the head of cancer. The first 
attempt to describe tumors upon an anatomical basis was made by 
Johannes Muller in his work on The Structure of Alorbid Growths, 
published in 1838. Virchow traced the tumor-cells to their histological 
origin, and thus laid the foundation for a rational classification. He 
was also the first to describe the alveolar structure of carcinoma, and 
he called attention to the resemblance of carcinoma-cells to epithelial 
cells. He believed that both stroma and the epithelial cells were pro- 
duced by the connective tissue. 

The microscope was made available as a means of investigating the 
structure of tumors by Schleiden and Schwann. Muller in 1836, in a 
preliminary communication, divided tumors into "benign" and "malig- 
nant," by which terms he meant tumors that were curable or incurable 
by operation. Bichat described carcinoma as a subepithelial tumor, and 
distinguished a stroma which he believed consisted of degenerated con- 
nective tissue and of cells derived from the epithelial layer. Laennec 



206 PATHOLOGY AND TREATMENT OF TUMORS. 

divided tumors into " homologous " and " heterologous," and among 
the latter included tubercle, encephaloid, melanosis, and scirrhus. Lob- 
stein, while admitting the correctness of this division, believed that the 
difference between the two kinds of tumors was due to a species of 
lymph, which, according to the character of the tumor, is either euplastic 
or cacoplastic. Miiller maintained that the structure of benign and 
malignant tumors was identical, and that the classification into homol- 
ogous and heterologous tumors was based on ignorance of their micro- 
scopical structure. He, however, recognized a neoplastic form of cell- 
elements, and in the examination of tumor-tissue under the microscope 
he speaks of normal tissue, granules, cells, and new connective tissue. 
From that time dates the description of a morphologically specific 
caudate cancer-cell which was regarded as the essential element of 
cancerous infiltration — an opinion which prevailed at his time, but 
which was not shared by Miiller. Lebert and Hannover revived again 
the theory of the existence of a specific cancer-cell, but, instead of the 
caudate cell, described a more primitive structure. Lebert separated 
carcinoma of the skin from carcinoma of internal organs, and called it 
cancroid. About the same time Ecker examined microscopically three 
specimens of carcinoma of the lip, and, finding no foreign heteroplastic 
cells, declared them to be a simple hypertrophy of the papillae. Mayo 
discovered general infiltration in a similar tumor, and therefore classified 
it with what was then generally recognized as cancerous tumors. 

Rokitansky classified carcinoma of the skin with glandular carci- 
noma, and regarded it as a variety of medullary fungus, differing from 
carcinoma proper only by the form and aggregation of its cells. Lebert 
modified his views regarding the structure and nature of cancroid after 
he discovered that in some cases it gave rise to glandular and general 
infection, and after having found in it the cell-forms which he regarded 
as characteristic of carcinoma. In 1845 he distinguished three kinds 
of carcinoma of the skin: 1. Papillary excrescences with inflamed, 
indurated base and superficial ulceration ; 2. Papillary proliferations of 
the cauliflower kind with enlargement of the sebaceous glands ; 3. Epi- 
thelial neoplasms consisting of a fibrous framework, its meshes filled 
with epithelial cells. Ecker, Mayo, and Lebert referred the origin of 
the new epithelial cells to proliferation from pre-existing mature epithe- 
lial cells, while Virchow, Rokitansky, and Neumann claimed that they 
were the product of metaplastic proliferation of the connective tissue. 
The glandular origin of carcinoma of the skin was studied by E. H. 
Weber, and later by Gluge. Ecker, Mayo, Lebert, and Rokitansky 
believed that carcinoma resulted from tissue-proliferation of the papillae 
of the skin. Virchow applied the term cancroid to surface carcinoma 



CARCINOMA. 207 

in which, in the tumor-tissue, spaces are formed and are occupied by 
epithelial cells. Fiihrer called attention to the possible influence of 
irritation caused by the hair in the production of carcinoma of the lip 
in men. Robin believed that carcinoma of the skin originated in the 
sebaceous glands. 

Hannover originated the term epithelioma for carcinoma of the skin 
and mucous membranes — a term which has caused a great deal of 
confusion in distinguishing a benign from a malignant epithelial tumor. 
He asserted that carcinoma of the skin originated from the rete Mal- 
pighii, and not in the glandular appendages of the skin. Verneuil and 
Forster observed cases of carcinoma of the skin that originated in 
sweat-glands. A parallel to the history of surface carcinoma is that of 
a form of ulceration of the skin that was called ulcere cancroide by 
Lebert, ulcus rodens by Paget, and ulcus phage dmnicum by Von Bruns. 
Many English authors adhere to the term rodent ulcer, and describe 
under it something which is supposed to be different from true carci- 
noma. Modern writers, with few exceptions, look upon rodent ulcer as 
a variety of carcinoma of the skin. Forster observed fatty degeneration 
of the tissues in carcinoma of the skin, besides a mucous metamorphosis 
of the cell-masses in the alveoli. Colloid degeneration was found only 
in exceptional cases. It was ascertained later that the cylindroma of 
Billroth also represents only a secondary change occurring in surface 
carcinoma. In but a few instances was a primary carcinoma found 
away from the epiblastic or hypoblastic tissues. Virchow reports a 
primary cancroid in the tibia ; O. Weber, in the inferior maxilla ; Paget, 
in the inguinal glands. In all these and in similar cases the prolifer- 
ation had its origin from a displaced matrix of embryonic epiblastic or 
hypoblastic tissue. Cohnheim went a step farther, and claimed that 
carcinoma did not originate by proliferation from mature epithelial cells, 
but that it was produced, independently of mature pre-existing tissue, 
from a matrix of embryonic epithelial cells, and he advanced the theory 
which assigns to the origin of all tumors a matrix of embryonic tissue. 
This theory has been upheld strongly by Waldeyer and a number of 
modern writers. It goes farther toward explaining the origin of tumors 
than any other theory heretofore advanced. Until quite recently car- 
cinoma was regarded as a local manifestation of a general dyscrasia. 
It was supposed that the essential cause existed in the blood, and that 
the tissues the seat of tumor-formation were acted upon by a specific 
virus. Virchow assumed the existence in the tissues of a primary 
carcinoma of a seminium which, by being brought in contact with 
lymphatic and other tissues, reproduced the disease in other localities, 
and which by its action upon the adjacent tissues gave rise to local 



208 PATHOLOGY AND TREATMENT OF TUMORS. 

infection. He asserts that in the primary formation no doubt there is 
produced a contagious material which acts upon the tissues with which 
it comes in contact in the same manner as does the lymph in lymph- 
glands. The more anastomoses the affected parts have, the more such 
a result may be expected. Cartilage is almost exempt from local infec- 
tion of a malignant growth, owing to the absence of blood-vessels and 
lymphatics. In malignant tumors in the epiphyseal region of the long 
bones the articular cartilage is often found completely separated, and 
shows the effect of pressure-atrophy rather than of direct implication 
by the tumor. He believes that local infection from a malignant growth 
takes place by the action of an infective fluid brought in contact with 
cells without the intervention of vessels or nerves. He admits that it 
is not known whether distant parts are infected in a similar manner or 
whether metastasis takes place by transportation of cells. He believes 
that the occurrence of metastatic carcinoma of the liver without carci- 
noma of the lung speaks against cellular transportation as a cause of 
metastatic tumors. W. Miiller and Creighton believe that the virus 
produced in a carcinoma affects the tissues with which it is brought in 
contact like the spermatozoa affects the ovum, the cell-impregnation 
giving rise to tissue-proliferation. 

Mr. Simon in a recent discussion on carcinoma took this standpoint. 
He attempted to show that the mere wandering of cancer-cells to parts 
distant from the primary tumor, and their overgrowth in their new loca- 
tion, did not explain the facts as observed in these tumors. He 
maintained that the essence of the specific force of malignancy is an 
impregnative or spermatic one, whereby the part primarily affected 
exercises on the tissue receiving its juices an influence which causes 
the latter " to fructify in conformity with its own deranged pat- 
tern." But then, again, holding these views, he still is able to 
see two functionally distinct classes of disease in cancerous and non- 
cancerous tumors. It is difficult to conceive how a modern path- 
ologist could hold such views in the face of the numerous and con- 
clusive proofs of dissemination of carcinoma by migrating and trans- 
planted cells. 

More recent researches have been made with a view of demonstrat- 
ing the microbic origin of the primaiy and secondary tumors, but so 
far no conclusive proof has been furnished of the microbic origin of 
carcinoma. Our present knowledge concerning the origin and growth 
of carcinoma warrants us in making the statement that carcinoma is the 
result of an atypical proliferation from a matrix of embryonic cells, and 
the local and general infections arc caused by the local and general 
dissemination of carcinoma-cells. 



CARCINOMA. 209 

Histogenesis. — In discussing the histogenesis of carcinoma we shall 
take it for granted that all carcinomatous tumors spring from a similar 
matrix — that is, that they all have a similar histogenetic origin. It has 
been stated elsewhere that the histological structure of the tumor and 
its behavior to the surrounding tissues are modified by the type of the 
cells of which it is composed and the nature of its environment ; but 
all cancerous tumors bear a resemblance to one another anatomically 
and manifest the same clinical tendencies. The idea that the old authors 
entertained in regard to the parasitic nature of tumors of all kinds, but 
especially of carcinoma, presents plausible features. Even normal cells, 
as Virchow says, live a parasitic life. In a stricter sense the term 
parasitic can be applied to cells which, when detached from their 
mother-soil, retain under favorable circumstances their vitality when 
transplanted into other localities, such as epithelial cells and cartilage- 
cells. If a piece of connective tissue should become detached and 
should engraft itself upon living tissue in some other place, it would 
have to be regarded as a parasite, as its existence would depend upon 
the abstraction of nutritive material from the new soil. The parasitic 
nature of malignant tumors is more marked than that of the benign 
growths, because a carcinoma or a sarcoma from its very commence- 
ment destroys pre-existing tissues, besides robbing the part in which 
it is located of a part of its nutritive supply. 

Parasitism of tumors, in the sense in which the expression is 
used to-day, is much more limited in its significance than formerly. 
When used in its modern sense, the term signifies the presence 
in the body of growths which have no existence in the normal 
body. We now regard a tumor as an integral part of the organ- 
ism, the product of tissue-proliferation from a matrix of embryonic 
cells. 

The first attempt to trace tumors to their proper histogenetic source 
was made by Virchow, who believed that the carcinoma-cells, like the 
cells of nearly all tumors, were derived from the connective tissue. 
He found cells in carcinoma far away from normal epithelial cells, and 
from their resemblance to epithelial cells he called them epithelioid cells. 
He believed that these cells were produced in the localities in which 
he found them. Forster believed that the cells of the cylinder-celled 
epithelial cancroid of the gastro-intestinal canal and the squamous 
epithelioma of the skin were produced by the pre-existing connective 
tissue of the part in which the tumor originated. Neumann supported 
Virchow's views in reference to the histogenetic source of the carci- 
noma-cells. Roster, a pupil of Recklinghausen, asserted that in carci- 
noma of the skin and the stomach the carcinoma-cells were derived 

14 



2IO PATHOLOGY AND TREATMENT OF TUMORS. 

from the endothelial cells of the lymphatic vessels. Virchow describes 
cell-formation in carcinoma as follows : "A portion of a large granular' 
cell becomes uniformly transparent, possibly beginning with a degener- 
ating nucleus. This portion shows from the first a definite wall, which 
becomes thickened and similar in appearance to cartilage-cells. During 
this change the remainder of the old cell becomes more homogeneous 
and frequently disappears entirely." He considers the cavities, or vacu- 
oles, in carcinoma-cells and in cartilage-cells identical. This condition 
seems to be the first step to overcome morphologically the apparently 
great differences between epithelial and cartilaginous structures. As 
illustrations of their close relation, instances of two tumors, one of 
the parotid gland and the other of the testicle, are given, in which 
tumors a portion was of epithelial and the remainder of cartilaginous 
structure. 

Virchow's views prevailed until Remak established the doctrine of 
the independence of the different histological elements and founded the 
law of the normal succession of cells. His supported Remak's teach- 
ing in a most positive manner. The same author added to our know- 
ledge of the histogenesis of epithelial tumors by excluding from them 
endothelial tumors. He regarded the endothelial cells as a variety of 
connective-tissue cell derived from a histogenetic source entirely differ- 
ent from the epithelial cells. In the light of recent embryological in- 
vestigations, the doctrine of metaplasia as expounded by Virchow is no 
longer tenable. Connective tissue cannot produce epithelial cells, and 
epithelial cells cannot produce connective tissue. The law of the legiti- 
mate succession of cells holds true in the growth of tumors, both benign 
and malignant, as well as in the production of normal tissue. The 
origin of carcinoma-cells from mature pre-existing epithelial cells was 
accepted by Billroth, Liicke, Rudnow, Thiersch, Klebs, Rindfleisch, 
and others. Waldeyer went a step farther in explaining the difference 
between the origin of benign and malignant epithelial tumors when he 
defined a carcinoma as "an atypical epithelial tumor." With this defini- 
tion he wished to draw a line between a benign and a malignant epithelial 
tumor. By an atypical proliferation of epithelial cells is meant a condition 
in which the new cells produced originally within the limits of epithe- 
lial tissue extend beyond the limits of the physiological type — that is, 
beyond the basement membrane. An adenoma (Fig. 118) as compared 
with a carcinoma (Fig. 119) is a typical tumor because the epithelial 
cells remain within their normal physiological boundary-line, the mem- 
brana propria. 

By contrasting Figures 1 18 and 1 19 it will be seen at a glance what 
is meant by a " typical " and an " atypical " tumor. Adenoma of the 



CARCINOMA. 



211 




212 PATHOLOGY AND TREATMENT OF TUMORS. 

breast is a typical epithelial tumor because the epithelial cells have at 
no place lost their normal relations with the connective tissue ; the 
cells and the connective tissue are separated by the membrana propria. 
Carcinoma of the tongue is an atypical epithelial tumor because the new 
epithelial cells have passed beyond the membrana propria and are 
beginning to infiltrate the connective tissue. The proliferation here is 
atypical because the epithelial cells are produced in a tissue of a differ- 
ent type and in a place distant from that in which they normally 
originate. 

To make the point between typical and atypical proliferation of 
epithelial cells still stronger the atypical proliferation will be defined 
as the presence, growth, and multiplication of epithelial cells in the ineso- 
blastic tissues. Klebs defines this process very correctly as " a meta- 
stasis of epithelial cells." 

Cohnheim believed in the epithelial origin of carcinoma, but asserted 
that mature epithelial cells are not capable of producing a tumor. He 
claimed that all tumors originate from a congenital matrix of embryonic 
cells. For carcinoma he assumed either a matrix of epithelial cells in 
localities in which epithelial cells normally exist, or a displaced matrix. 
From this standpoint all tumors are atypical. We shall, however, use 
the word " atypical " in the sense in which Waldeyer applied it. We 
shall hold fast to Cohnheim's theory regarding the histogenesis of car- 
cinoma. If a carcinoma always originates from epithelial cells, primary 
carcinoma in mesoblastic tissue is impossible from a histogenetic stand- 
point unless a matrix of embryonic epithelial cells has become displaced 
during the development of the embryo, or when epithelial cells have become 
buried in mesoblastic tissues, after birth, by injury or by disease. Primaiy 
carcinoma of mesoblastic tissues is due to the presence of a displaced 
matrix of embryonic epithelial cells. It is from such matrices that 
primary carcinoma is occasionally observed in bone, in lymphatic glands, 
and in other mesoblastic tissues. Deep-seated carcinoma of the neck 
occurring independently of infection from another source originates 
either from branchial structures — branchiogenous carcinoma (Volk- 
mann) — or from an accessory or supernumerary thyroid gland— struma 
carcinomatosa accessoria (Guttmann). 

The origin of carcinoma in accessory organs must be taken into 
consideration in the diagnosis of primary carcinoma in unusual localities. 
A post-natal matrix of embryonic epithelial cells is more frequently the 
starting-point of carcinoma than was formerly supposed. Such a matrix 
is created in ordinary scar-tissue in scars following deep burns, in 
ulcers, and by the traumatic displacement of fragments of epithelial 
tissue. 



CARCINOMA. 



213 



Histology. 
All carcinomatous tumors are composed of epithelial cells and an 
alveolated stroma of connective tissue. One of the strongest argu- 
ments against the microbic origin of carcinoma is the histogenetic 
source of the carcinoma-cells. Pathogenic microbes act upon the 
tissues with which they are brought in contact, and the proliferation 
results in cells which correspond in type with the cells acted upon 
by the microbes. Carcinoma-cells multiply by karyokinesis. Soon 
after Flemming published the result of his observations on karyo- 




Fig. T20. — A cell-nest from a cancer of the lip ; X 300 (after D. J. Hamilton) : a, the stroma of the alve- 
olus in which the cell-nest is contained; b, small germinal cells of the periphery; c, prickle-cells; d, com- 
pressed squamous cells; e, degenerated cells in the centre. 

kinesis, Filbry observed the same structural changes in carcinoma-cells. 
All preparations showed, without exception, the indirect mitotic seg- 
mentation of the nucleus. The best figures were seen in the marginal 
zone of the epithelial projections, while in sarcoma they were about the 
same throughout the tumor. The epithelial cells are derived from the 
essential tumor-matrix ; the stroma consists of pre-existing connective 
tissue. The several varieties of carcinoma formerly separately described 
— epithelioma, scirrhus, encephaloid, colloid, glandular carcinoma — differ 
only in their structure from their location, the type of cells, or the kind 
and degree of degeneration of the tumor-tissue ; the general plan of 
their histological structure is the same. For the purpose of avoiding 



214 PATHOLOGY AND TREATMENT OF TUMORS. 

confusion the different histological forms of carcinoma will be described 
separately. 

Squamous-celled Carcinoma. — The characteristic histological feat- 
ure of every carcinoma is the alveolation of the stroma and the group- 
ing of cells in its meshes (Fig. 120). 

In carcinoma of the skin the squamous epithelial cells are arranged 
in concentric layers in the alveoli, forming the so-called " cancer-nests " 
or " epithelial pearls." The young cells occupy the periphery of the 
nest, the oldest cells being in the centre. Cell-degeneration always 
begins in the oldest cells in the centre of the nest. The alveolated 
structure of the stroma was first described by Virchow. The alveoli 
are formed by the colonies of cells which form in the connective-tissue 
spaces, each colony the offspring of a single epithelial cell which has 
found its way into the connective tissue. As the cell-mass increases in 
size the connective-tissue fibres are separated and form the alveolus. 
The epithelial cells act the part of a foreign body and increase the 
blood-supply to the tissues, thus increasing the vegetative capacity of 
the connective-tissue cells, which in turn results in increase of the 
stroma. 

Klebs believes that the epithelial cells which have undergone carci- 
nomatous degeneration are gradually transformed into connective tis- 
sue and form a part of the stroma. If such a transition occurs, the 
increase of stroma-tissue during the growth of the carcinoma could 

easily be explained. Hatschek and 

_ .-s:;"S,j- \ ;,--■ v Rabl claim that mesoblastic cells are 

y\ " v ' ^ derived from epithelia. Reckling- 

,s\ ',;':'' *./.'. :<;"}'-'■ '...i .-'-':: ' : ".^t hausen and Koster have observed 

• , ' ' ,,'■':.'/"' ~ .r7. — "l"^ — " metaplastic tissue-changes in meta- 

'Vi?'.'' '<;-.; "'",'■ ~?\ •■>■'-■ -' jV -X'''£0iu< static lymphatic carcinoma, where 

^'0'p'r'-l/-i /'■ylh£p(&'f;;l endothelial cells were transformed 

M - ~ - , - — ^1^__L c into epithelial cells. These views can 

- , - no longer be held, as more recent 

' -<siii-*> srfi.h researches have established upon a 

Fig. 121.— Artery from connective-tissue stro- firm basis the law formulated by 
ma of secondary carcinoma of the lower jaw: -p, . , r . , TT . . 

endarteritis deformans et obliterans ; x 54 (Sur- Remak and confirmed by His, that 
gicai clinic, Rush Medical college, Chicago) : ce n s invariably produce their own 

a, thickened proliferating intima ; b, internal i 

elastic lamina ; c, tunica media. kind, and no other. We must there- 

fore assign to the pre-existing con- 
nective tissue the function of stroma growth. 

The stroma is always infiltrated by leucocytes and young carcinoma- 
cells (Fig. 121, a). In rapidly-growing soft carcinoma the stroma is 
scanty, the alveoli is large, the cells are numerous, and the local infection 



CARCINOMA. 



215 



is early and extensive. A well-developed, firm stroma renders the 
tumor hard and retards its growth and local infection. The vessels and 
lymphatics of a carcinoma are distributed through the stroma. The 
arteries in the carcinomatous tissue frequently undergo degenerative 
changes, which have not been studied with sufficient care since Thiersch 
first called attention to them. 

Proliferating endarteritis has been found a rather frequent accompani- 
ment of carcinoma in the laboratory of Rush Medical College, when 
there were no indications of the existence of the same condition of the 




Fig. 122. — Carcinoma of the skin ; X 450 (Surgical Clinic, Rush Medical College, Chicago) : a, stroma 
infiltrated by leucocytes and young carcinoma-cells; <5, epithelial nest; c, colloid degeneration in centre of 
pear! ; d, new cancer-nest. 

arteries in any other part of the body. The existence of this form of 
arterial degeneration on a large scale cannot but give rise to serious 
nutritive changes of the tumor-tissue (Fig. 122). It is a subject that 
calls for further investigation. 

Cylindrical-celled Carcinoma. — In carcinoma of the mucous mem- 
brane derived from the hypoblast the parenchyma of the tumor is 
composed of cylindrical cells arranged in the form of tubules in resem- 
blance of tubular glands. The tubules correspond with the cell-nests of 
squamous-celled carcinoma (see Fig. 28, p. 67). The columnar epithelial 



2l6 



PATHOLOGY AND TREATMENT OF TUMORS. 



J:^5-. ;>J **i>„ 



cells are arranged in a somewhat atypical manner in the crypts, forming 
a cellular lining of differing depths (Fig. 123). The tubules vary in size 
and shape, constituting in this respect a contrast to adenoma of the same 
part, in which symmetry of the tubules is pre- 
served (Fig. 124). The stroma of the tumor 
is infiltrated with leucocytes and young carci- 
noma-cells (Fig. 124, c). The cells and stroma 
of cylindrical-celled carcinoma are prone to 
undergo mucoid and colloid degeneration. 

Glandular Carcinoma. — Carcinoma of the 
acinous glands presents the same alveolation of 
the stroma as squamous-celled carcinoma. The 
morphology of the cells being similar, the gland- 
ular spaces correspond with the connective-tissue 
spaces, in which, in the latter variety, the epithe- 
Fio. 123.— a single mbuie from lial cells establish centres of growth and form 
a carcinoma of the rectum, show- the a i veo ij j n glandular carcinoma the acini 

ing multiplication of cells in its 

lining; x 170- At a, shrinkage constitute the alveoli, and the interacinous 

duetohardening(SurgicalClinic, connective t j ssue const j tute s the Stroma (Fig. 
Rush Medical College, Chicago). V o 

125). In hard, slow-growing glandular carci- 
noma the stroma is abundant and the alveoli are small. In soft, 
rapid-growing carcinoma, formerly called " encephaloid," the stroma 











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■',■}_;., 



Fig. 124.— From carcinoma of the rectum; X no (Surgical Clinic, Rush Medical College, Chicago); 
a, atypical tubule ; b, intratubular growth of cells ; c, extratubular infiltration. 

is scanty and the alveoli are large. A strong reticulum imparts to 
the tumor benign qualities. 

Malignancy. 
The clinical interest of carcinoma centres on its malignancy. 
Malignancy depends not upon the progressive increase in the size 
of the tumor, as is the popular belief, but upon the extension of the 



CARCINOMA. 



217 



tumor to near or distant parts and organs. The intrinsic tendency of 
carcinoma is to destroy life. For the lack of a better word, the pro- 
cess by which the tumor diffuses itself in its immediate vicinity, in the 
same region, and throughout the entire body, is termed " infection." 




Fig. 125. — Glandular carcinoma of mamma ; X 85 (Surgical Clinic, Rush Medical College, Chicago) : a, con- 
nective-tissue stroma; b, alveoli packed with epithelial cells. 



By the term "infection " as applied to malignant tumors is meant the 
intrinsic capacity of their cells to leave the primary tumor, and by 
wandering into the surrounding healthy tissue to establish new centres 
of growth, or by being transported through pre-existing channels to 
reproduce the disease in the same region or in distant parts of the 
body. 7/ is this cell-migration, and the intrinsic capacity of the cells to 
reproduce themselves in new and strange localities, that distinguish malig- 
nant from benign tumors, and upon which depends their malignancy. 

Local Infection. — The power of epithelial cells to penetrate into 
the apparently healthy tissue, as seen and described by Waldeyer and 
Thiersch, is evidenced in the local diffusion of every carcinoma, but it 
does not explain the malignancy of the tumor, as normal epithelial 
cells do not possess the same power to proliferate in mesoblastic tissues 
as do the epithelial cells of a carcinoma. The epithelial cells have 



2l8 



PATHOLOGY AND TREATMENT OF TUMORS. 



therefore undergone a change, the true nature of which is unknown, 
which endows them with a greatly augmented vegetative capacity. In 
the present state of our knowledge we must attribute this increase of 
their formative power, not to a change in the cells themselves, but to 
an altered condition of the tissues which they inhabit. This latter 
condition we have described as a diminution of physiological resistance. 

An anomalous location of epithelial cells under certain conditions 
may cause carcinoma ; this anomaly, however, does not constitute the 
real cause, but is only an additional factor, and not an essential ante- 
cedent condition. 

Every carcinoma has a benign stage. No matter where the matrix 
may be located, the cells composing it are at first isolated from the vas- 
cular tissues, and the carcinomatous stage begins with cell-migration. 
Local infection — that is, the growth of the tumor as a whole — is the 
result of cell-migration. The new epithelial cells, like the ameba and 
leucocytes, possess the power of independent locomotion. The ameboid 




Fig. 126.— From an epithelial carcinoma of the clitoris : epithelial nests imbedded in a stroma infiltrated 
by small cells ; X 250 (after Perls). 

movements of carcinoma-cells were studied in 1872 by Carmalt in 
Waldeyer's laboratory. Cells of carcinoma of the breast obtained im- 
mediately after amputation constituted the material used. The cells 
were detached by scraping the cut surface of the tumor, and were kept 
immersed on the thermal object-table of Strieker. The isolated young 
cells manifested active ameboid movements, while the deeper cells in 
fragments of tissue remained motionless. 



CARCINOMA. 



219 



In the stroma of every carcinoma small young epithelial cells 
besides leucocytes are found (Fig. 126). This infiltration of the tissues 
around a carcinomatous tumor was called by Waldeyer the " inflam- 
matory zone." Leucocytes escape through damaged capillary walls and 
are present in large number in rapidly-growing carcinoma, but among 
them young carcinoma-cells can always be seen. All these young 
epithelial cells, as soon as they have isolated themselves from the 
primary tumor, assume an individuality of their own and establish 




Fig. 127. — Colloid carcinoma of the colon : section through the margin of the tumor; X 21 (after Karg 
and Schmorl). The tumor (c), which started in the mucous membrane {a), has perforated the muscular 
coat {b) and presents an adenomatous structure. 

independent centres of tumor-formation. In cylindrical-celled carci- 
noma the membrana propria of the tubules is often absent, bringing 
thus the carcinoma-cells in direct contact with the vascular connective 
tissue, which they infiltrate, increasing thereby the size of the tumor and 
the area of tissue-proliferation. The glandular tubules are irregularly 
branched, are devoid of the membrana propria, and are lined in places 
by three layers of columnar cells (Fig. 127). To the right of the tumor 



220 



PATHOLOGY AND TREATMENT OF TUMORS. 



is to be seen a second carcinomatous nodule (d) which is undergoing 
colloid degeneration. Only at the periphery can carcinoma-cells be 
seen, while the centre of the space is occupied by colloid material and 
degenerated detached cells. The space is enclosed by the muscularis (<•). 
In glandular carcinoma the infiltration takes place in all directions, and 
the tumor is surrounded on all sides by a zone of new alveoli, the con- 
tents of each alveolus being the product of proliferation of a single cell. 
New alveoli are also found in the stroma, especially in rapid-grow- 
ing tumors, rendering the tumor softer by diminishing its stroma 
(Fig. 128, b,b). 

The local infection of carcinoma takes place in the direction of pre- 
existing connective-tissue spaces, and consequently spreads most rap- 




Fig. 128. — Rapid-growing carcinoma of the breast ; X "5 (Surgical Clinic, Rush Medical College, 
Chicago): a, vascular stroma; b, b, alveoli packed with large epithelial cells. 



idly and becomes most extensive in cases in which the primaiy tumor 
is surrounded by an abundance of loose connective tissue. It is in 
such cases that the tumor attains the largest size. The local infection, 
however, does not remain limited to the connective tissue. Carcinoma 
involves by local extension all tissues and organs, irrespective of their 
anatomical structure. This is the most conspicuous pathological and 
clinical feature of all carcinomatous tumors. Johannes Muller called 
special attention to this property of carcinoma, and surgeons have always 
regarded this feature as of the utmost diagnostic value in the differen- 
tiation between benign tumors and carcinoma. Neumann described 
and illustrated carcinomatous infiltration of muscular tissue, guided 
by the belief that the carcinoma-cells were produced by the inter- 



CARCINOMA. 221 

muscular connective tissue. The tissues and organs the seat of local, 
regional, and general dissemination remain passive in the growth of 
carcinoma ; the increase in the size of the tumor is due exclusively to 
tissue-proliferation of -wandering displaced carcinoma-cells. The cells 
of the regional and metastatic tumors arc derivatives from the primary 
or maternal tumor. Diffuse local infection favors early regional and 
general infection. It is on this account that glandular carcinoma is 
followed more constantly and at an earlier stage by regional and gen- 
eral infection than is squamous-celled or cylindrical-celled carcinoma. A 
carcinoma of the cutaneous or mucous surfaces lias only one direction in 
zvhich to infiltrate the tissues, while a glandular carcinoma is surrounded 
by mesoblastic tissues on all sides, with a correspondingly increased area 
of infiltration. 

The progressive growth of a carcinoma is due to the establishment 
of independent centres of growth in the periphery of the tumor. It is 
for this reason that spontaneous sloughing of the tumor and its destruc- 
tion by caustics is not followed by a cure, as is the case in benign growths. 

Regional Infection. — It is a well-known clinical fact that a carcinoma, 
wherever it may be located, gives rise to infection of the lymphatic 
glands of the same region. Simon and Paget were of the belief that 
carcinoma extends from the primary tumor, not through any active 
part of the interposed lymphatic channels, but through the lymph. 
They explained regional infection as follows: I. The disease in the 
lymphatic glands resembles the primary tumor, the deviation being 
dependent on the structures surrounding the carcinoma in the lym- 
phatic gland ; 2. It appears about midway in the course of the disease 
toward death ; 3. Usually the primary tumor makes more rapid prog- 
ress, but occasionally the reverse is the case ; 4. The disease extends 
along the lymphatics in the direction of the thoracic duct ; distant lym- 
phatics are rarely affected. Paget believes that minute fragments of 
the protoplasm of the cancer-cells, mingled with the blood, may be as 
effectual as whole cells in reproducing the disease. 

The migrating young epithelial cells find their way into the lym- 
phatic vessels within or near the primaiy tumor, are carried by the 
lymph-stream to the nearest lymphatic gland, which serves as a filter, 
arresting their further progress, and as soon as they become localized 
they establish new centres of growth in the lymphatic gland. There 
must exist in the primary tumor or in its vicinity favorable conditions 
for the entrance of the cells into the lymphatic channels. 

Langhans made a careful study of injected preparations of the 
mammary gland, with the special object of ascertaining the relations of 
lymphatics to the acini and ducts of the gland. He found the acini 



222 



PATHOLOGY AND TREATMENT OF TUMORS. 



and ducts surrounded by a delicate network of lymphatic vessels, but 
in none of the specimens did the lymphatic vessels reach the interior 
of the acini or ducts, or even the membrana propria. Such a direct 
communication between these structures is claimed by Ludwig Tomsa. 
The abundance of lymphatic vessels in the mammary gland is well 
shown in Figure 129. The lactiferous tubes are also partially injected, 
and may be seen under the network of lymphatics. It is more than 
probable that normal lymphatic vessels are impermeable to emigrating 




Fig. 129. 



-The internal lymphatics of the mammary gland injected, and terminating in two trunks in the 
axilla (after Astley Cooper). 



epithelial cells, and that their entrance is effected by destruction of the 
wall of pre-existing lymphatics or through the defective walls of new 
lymphatic channels in the tumor-tissue. This subject is well worthy 
of a most careful investigation. Gussenbauer maintained that second- 
ary carcinoma of the lymphatic glands results from the transportation 
of minute infective corpuscular elements which are carried from the 
primary tumor through the lymphatic channels into the lymphatic 
glands, where they infect pre-existing glandular tissue, bringing about 
a heterologous change in the tissue-elements resembling the structure 
of the primary tumor. He found in sections of glands recently infected, 
on staining with picro-carmine, minute granules of an intense red color 
in the cells of the infected gland-territory. The cells thus infected then 
presented various changes in their structure. This theory was in accord 



CARCINOMA. 



223 



with views expressed by Virchow and Creighton, that cancer-cells are 
produced by the action of a virus or saninium upon mature cells. We 
have shown conclusively that the cells of which the primaiy tumor is 
composed are derived not from mature tissue, but from a matrix of 
embryonic epithelial cells, and we shall now proceed to prove that all 
metastatic tumors, local, regional, and distant, owe their origin and 
growth to cells derived from the primary tumor. 

Afanassiew made some very interesting investigations in Rudnew's 
laboratory at St. Petersburg concerning the growth of secondary car- 
cinoma in the lymphatic glands. Inflammatory enlargement of the 
glands is observed only when the carcinoma has ulcerated, and is then 
caused by the entrance into the lymphatic system of pathogenic mi- 
crobes or of chemical irritants. Enlargement of the lymphatic glands 
under other circumstances denotes the regional dissemination of the 
disease. The first changes observed in such glands are the presence 
of carcinoma-cells from the primary tumor in the lymphatic channels, 
and irritation of the connective-tissue reticulum caused by the invaders. 
The lymphoid corpuscles take no active part in the process. As the 
carcinoma increases in size by proliferation of the transplanted carci- 
noma-cells new connective tissue is formed from the granulation- 
elements. The parenchyma of the 
gland is subjected to pressure and 
is gradually destroyed, its place 
being occupied by carcinoma- 
tissue. The carcinoma-cells that 
reach the interior of the lymphatic 
channels are conveyed with the 
lymph-current to the nearest 
lymphatic gland, in the meshes 
of which their onward course 
becomes arrested. As soon as 
a wandering carcinoma-cell has 
reached its destination it under- 
goes karyokinetic changes, and 
the product of tissue-proliferation 
constitutes the secondary gland- 
ular tumor, the connective tissue 
of the gland becoming its stroma 
(Fig. 130). 

The stroma of the carcinoma 
is derived from the pre-existing reticulum of the 




Fig. 130.— Secondary carcinoma of lymphatic 
gland: X 480. reduced one-third (Surgical Clinic, 
Rush Medical College, Chicago) : n, groups of carci- 
noma-cells ; I), lymphoid corpuscles and reticulum. 
Each one of the epithelial nests is the product of 
tissue-proliferation of a single carcinoma-cell. 



land, which reticu- 



lum is increased in consequence of the stimulation caused by the 



224 



PATHOLOGY AND TREATMENT OF TUMORS. 




carcinoma-cells, which act the part of a foreign body. Simultaneously 
or in succession additional centres of growth may become established 
in different parts of the gland by new cells emerged from the primary 

tumor to the lymphatic gland. 
New centres of growth are, 
however, exhibited also by the 
migration of young epithelial 
cells from the first glandular 
focus along the lymph-spaces 
into other parts of the gland 
(Fig. 131,4 

The local infection of sec- 
ondary tumors is as marked 
as that of the primary tumor, 
and takes place in the same 
manner. The cells corre- 
spond in shape, size, and 
manner of grouping to those 
of the primary tumor. The 
stroma is modified by the 
character and amount of 
connective tissue in the new 
locality. It has been known for a long time that a secondary tumor 
frequently grows much more rapidly than the primary tumor. This 
fact can readily be explained by assuming that the pre-existing connec- 
tive tissue surrounding the secondary tumor is more scanty and of a 
looser structure than the stroma of the primaiy tumor. As the local 
infection in the lymphatic gland increases, the parenchyma of the gland 
disappears until its capsule becomes distended by carcinomatous tissue. 
During this time the capsule of the gland has become thickened in a 
vain attempt to limit further extension of the disease. As soon as the 
capsule is reached by the carcinoma-cells infiltration takes place, the 
capsule itself becomes carcinomatous, and the zone of infiltration 
extends now to the loose paraglandular connective tissue. Until now 
the gland has remained movable, but as soon as the disease reaches the 
surrounding tissues the gland becomes immovably fixed. 

From what has just been said in reference to the local infection of 
lymphatic secondary carcinoma it will be seen that enucleation of car- 
cinomatous glands is bad practice. Such practice prevails still to a 
large extent, and is responsible for the local recurrence that invariably 
follows such a procedure. Not only the paraglandular zone of infiltra- 
tion remains, but also the connecting lymphatic channels. 



Fig. 131. — Secondary carcinoma in the lymph-spaces of 
a lymphatic gland, from a carcinoma of the abdominal wall ; 
X 480, reduced one-third (Surgical Clinic, Rush Medical Col- 
lege, Chicago) : a, lymph-spaces ; b, groups of carcinoma- 
cells ; c, carcinoma-cells in the parenchyma of the gland; d, 
leucocytes. 



CARCINOMA. 225 

Carcinoma of the lymphatic channels has not received the attention 
it deserves. The writer is firmly convinced that many of the second- 
ary glandular tumors that have invariably been regarded as infected 
lymphatic glands were carcinomatous nodules which developed in the 
lymphatic vessels. There is no reason to doubt that carcinoma-cells 
may by mural implantation become arrested in lymphatic vessels and 
produce the same results as in a lymphatic gland. The number of 
nodules removed from the axillary space in operations for carcinoma of 
the breast frequently exceeds by far the number of normal lymphatic 
glands in that locality. For the purpose of removing the zone of infil- 
tration around carcinomatous glands, as well as with a view of removing 
all the connecting lymphatic channels, the radical operation for regional 
carcinoma should consist in the removal by clean excision of the entire 
lymphatic apparatus in that locality, with the surroiinding connective and 
adipose tissue. 

Regional infection is always progressive. Epithelial cells from the 
first secondary tumor reach the efferent part of the lymphatic vessel 
and are conveyed to the second lymphatic gland, where the same pro- 
cess repeats itself, until finally, if the disease is allowed to pursue its 
course and the patient lives long enough, the last of the chain of 
glands is reached, when the cells from this tumor reach the thoracic 
duct and from there the general circulation, producing metastatic tumors 
in distant organs. Regional infection through the deep lymphatic 
glands begins near the primary tumor, and extends from there, from 
gland to gland, until the last filter is passed, when general infection 
takes place. Regional infection retards, and frequently prevents, general 
infection. Surgeons are aware of the fact that in the most rapidly fatal 
cases the lymphatic infection is either entirely absent or, at any rate, 
not well marked. Usually the lymphatic affection occurs in the same 
region as that occupied by the tumor. For instance, in carcinoma of 
the breast the axillary glands on the same side, in carcinoma of the 
rectum the retro-peritoneal glands behind the rectum, and in carcinoma 
of the lip the submental and submaxillary glands, are affected. The 
writer not long ago observed a case of carcinoma of the breast with 
extensive regional infection of the axillary glands. Local recurrence 
soon after the operation was followed by enlargement of the inguinal 
glands first on one side and then on the other. Microscopic exam- 
ination of sections taken from these regions showed typical gland- 
ular carcinoma. 

Local infection through the superficial lymphatics of the skin travels 
as often against as -with the lymph-current. The extension of carcinoma 
through the superficial lymphatics of the skin, as observed in cases of 

15 



226 PATHOLOGY AND TREATMENT OF TUMORS. 

lenticular carcinoma, always reminds one of the manner of spreading 
of erysipelas. In such cases the lymphatic vessels take an important 
part in the diffusion of the disease. Lymphatic channels become 
blocked, the lymph-current is arrested, and consequently the direction 
of the dissemination of the disease is no longer governed by the lymph- 
stream. The original infection takes place in all directions. The swell- 
ing of the arm in extensive regional infection of the axillary glands 
is the combined result of lymphatic obstruction and pressure of the 
glandular tumors upon the large axillary vessels. 

General Infection. — General infection in carcinoma consists in the 
appearance of carcinomatous tumors in organs or tissues of the body 
that have anatomically no connection with the region occupied by the 
primary tumor. Such tumors are called " metastatic tumors," and the 
process by which they are produced is termed " metastasis." Klebs 
speaks of a " cell-metastasis " in local and regional infection of a carci- 
noma, but we shall restrict the term " metastasis " to tumor-formation 
anatomically disconnected with the primary tumor. Carcinoma-cells 
retain their vitality and intrinsic power of tissue-proliferation during their 
journey through the lymphatic vessels and blood-vessels, and as soon 
as they become arrested by mural implantation or embolism they begin 
to proliferate and to produce tumors identical with the primary tumor. 
Metastatic carcinomatous tumors always occur in connection with a 
blood-vessel on the arterial side of the circulation. The process of 
distribution of tumor-tissue resembles embolism. Generalization of car- 
cinoma takes place in consequence of the entrance into the general circu- 
lation of carcinoma-cells or fragments of tumor-tissue, which, when 
arrested anyivlierc in the arterial system, constitute carcinomatous emboli 
from which the metastatic tumors grow. The entrance of carcinoma- 
cells into the general circulation is effected in two ways: i. Direct 
entrance by perforation of a vein-wall by the tumor; 2. Migration of 
cells through the lymphatic system. In the first instance isolated 
tumor-cells may be washed away from the projecting tumor-mass, or 
fragments maybe broken off and conveyed into the general circulation. 
In the second manner of general dissemination isolated cells reach the 
venous circulation through the thoracic duct by migration of cells 
through the lymphatic channels and glands from the primary tumor 
without causing lymphatic carcinoma ; or, what is usually the case, carci- 
noma-cells enter from the last gland of the chain of lymphatic glands in 
the region occupied by the primary tumor, reach the thoracic duct, and 
from there the venous circulation. The location of the metastatic tumors 
is determined largely by the sirje of the carcinomatous emboli. Isolated 
small epithelial cells can pass through the pulmonary capillaries, reach 



CARCINOMA. 



227 



the arterial circulation, and become arrested in the minute capillaries 
of some distant organ as minute emboli ; or they adhere to the intima 
of the arterioles or capillaries, mural implantation takes place, and the 
cell becomes the starting-point of a metastatic tumor. Large tumor- 
fragments become arrested as emboli in the branches of the pulmonary- 
artery (see Fig. 31, p. 78). 

General dissemination by isolated cells frequently gives rise to miliary 
carcinosis ; the fragments of tumor-tissue, to embolism of the pulmonary 
artery. A metastatic tumor of the lung becomes a distributing-point of 
carcinoma-cells, which from here reach the general circulation, becom- 
ing the direct cause of more remote metastatic tumors or, perchance, 
of miliary carcinomata. All histological varieties of carcinoma may give 
rise to metastatic carcinoma, and all vascular organs of the body may be- 
come the seat of a metastatic carcinoma. The type of cells of the primary 
tumor is reproduced in the metastatic tumors ; that is, a squamous- 
celled carcinoma produces a squamous-celled metastatic tumor ; a colum- 
nar-celled carcinoma, a columnar-celled metastatic tumor, etc. It seems 
that this reproduction of tissue of a similar structure is a strong proof 
against the microbic origin of carcinoma, and a convincing argument in 
favor of the doctrine that carcinoma is the result of erratic growth of epi- 
thelial cells, and that local, regional, and general dissemination is caused by 
the migration and transportation of cells derived from the primary tumor. 

The lungs and the liver are the organs most frequently the seat of 
metastatic carcinoma. 

Wagner of Chicago has collected fifteen cases of metastatic car- 
cinoma of the choroid, and has made some interesting observations 
in reference to the manner of local 
diffusion of the metastatic tumors in 
this locality. Rapid local dissemina- 
tion of the tumor in this locality ap- 
pears to be one of its main clinical 
features. In the case that came under 
Warner's observation, and illustrated 
by Figure 132, the primary tumor was 
a carcinoma of the stomach. If a large 
branch of the pulmonary artery is ob- 
structed by a carcinomatous embolus, 
hemorrhage around the infarct is of 

0111 Fig. 132. — Metastatic carcinoma of choroid 

frequent occurrence, bkrzeczka de- (after Carl Wagner) . 

cribes such a case. The entire lung 

was the seat of hemorrhagic infiltration. Lebert examined twelve cases 
of colloid carcinoma of the gastro-intestinal canal, and found meta- 




228 



PATHOLOGY AND TREATMENT OF TUMORS. 



stasis in eleven of them. Hauser made a special study of metastatic 
carcinoma of the liver to determine whether the pre-existing liver- 
substance takes an active part in the growth of the tumor. He found 
that the parenchyma-cells in the vicinity of the carcinomatous nodules 
were destroyed and took no part whatever in the growth of the tumor, 
thus confirming the observations made by Thiersch and Waldeyer. 



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'«% 






^ifi*0M 










Fig. 133- — Metastasis of a rectal carcinoma in the lungs ; X 36 (after Karg and Schinorl). The nodule 
in the lung resembles in structure the primary tumor. It is composed of tubules lined by a single layer of 
columnar epithelium imbedded in a delicate stroma of fibrillated connective tissue. The emphysematous pul- 
monary tissue in the upper part of the picture is sharply defined against the border of the nodule. 

It will be seen from Figures 133 and 134 that the glandular structure 
of the metastatic tumors corresponds with the type of the epithelial 
cells and the structure of the primary tumors. 

If a carcinomatous embolus becomes impacted in an artery or in a 
branch of the portal vein, the metastatic tumor first fills the lumen 
of the vessel — that is, a carcinomatous thrombus forms around the 
embolus (Fig. 135). As soon as the pre-existing space in the lumen 
of the vessel becomes completely blocked by the endovascular meta- 
static carcinoma, the wall of the vessel becomes infiltrated and is soon 



CARCINOMA. 



229 



incorporated in the tumor. After this time the paravascular tissues 
become successively involved, and on examining such tumors all traces 
of the original vessel-wall have disappeared and nothing remains to 
indicate the endovascular origin of the tumor. 

Carcinoma of bone, with very rare exceptions in which the tumor 
develops from a displaced epiblastic matrix, is the result of metastasis. 




Fig. 134. — Metastasis of a carcinoma of the breast in the liver; X 40 (after Karg and Schmorl). The 
carcinomatous nodule (a), which is quite sharply separated from the parenchyma of the liver (/?), consists 
of narrow cellular cords imbedded in a coarse reticulum of connective tissue. 



Metastatic carcinoma of bone (Fig. 136) is a frequent cause of so-called 
"spontaneous fracture." Fractures occurring under such circumstances 
should be called " pathological fractures," to distinguish them from 
fractures resulting from trauma. The writer has observed metastatic 
carcinoma of bone most frequently in aged women suffering from latent 
carcinoma of the breast with moderate or no regional infection. 

In metastatic carcinoma of bone spontaneous fracture usually occurs 
before any external swelling has developed. If life is sufficiently pro- 
longed, a tumor appears later at the site of fracture. As Rokitansk-y 



230 PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 135. — Carcinomatous embolus in a branch of the portal vein after primary carcinoma of the breast; 
X 250 (after Karg and Schmorl). The branch of the portal vein (a) is dilated and filled by a plug of carci- 
noma-cells ; b, bile-duct. The surrounding liver-tissue is normal. 

says: " Cancer of the bone appears sometimes in the form of a nodule, 




Fig. 136. — Metastatic carcinoma of bone (after Hickmann) ; enlarged Haversian canals filled with carcino- 
matous tissue. 

of about the size of a walnut or a hen's egg, which is developed mostly 
in the medullary canal of the long bones ; it displaces the bony tissue. 



CARCINOMA. 



231 



and, producing atrophy of it by pressure, is frequently the cause of one 
or more spontaneous fractures of the bone which occur as the result 
of the most trifling causes." Union of the fracture by bony callus, 
despite the growth of the carcinoma, occasionally takes place. 

In patients suffering from advanced carcinoma the bones often 
become so brittle that fracture occurs upon the application of slight 
force without metastatic carcinoma. Paget remarks : " But some of 
the spontaneous fractures in cancerous patients are due to the wasting 
and degenerate atrophy which the bones undergo during the process 
of cancer, and which seems to proceed to an extreme more often than 
in any other equally emaciating and cachectic disease." There is, how- 
ever, reason to believe that in most cases of spontaneous fracture with- 
out tumor-formation, in which it was believed the fracture occurred 
without implication of the bone, the fracture was the result of the 
secondary bone-carcinoma, which was overlooked, life not being suf- 
ficiently prolonged for the appearance of a swelling. In favor of this 
view is the fact that pathological fractures under such circumstances 
are seldom multiple, which would be the case if the marasmus of car- 
cinoma produced general atrophy of the bones. The carcinomatous 
material is previously deposited in the Haversian canals, along which it 
infiltrates the bone, producing enlargement of the canals. 

Miliary carcinosis very closely resembles miliary tuberculosis. 
Demme reported seven cases of miliary carcinosis, and, basing his 
opinion regarding its etiology upon a study of the clinical history of 




Fig. 137.— Carcinomatous capillary embolism of the choroid; X 320 (after Perls): b, capillary net dilated 
and filled partly with red blood-corpuscles and partly with carcinoma-cells ; c, large nuclei. 

these cases, came to the conclusion that it is most frequently produced 
by trauma. The diffuse general dissemination of carcinoma is usually 
initiated by a rise in temperature and by other febrile disturbances that 



232 PATHOLOGY AND TREATMENT OF TUMORS. 

closely simulate the general symptoms which inaugurate and attend 
miliary tuberculosis. In almost all organs of the body, and more par- 
ticularly upon the serous surfaces, innumerable nodules, from the size 
of a mustard-seed to that of a hempseed, appear. The nodules are 
produced by capillary emboli composed of carcinoma-cells (Fig. 137). 
Miliary carcinosis is a rapidly fatal affection. It is probably produced 
most frequently by perforation of a vein-wall by the primary or a 
secondary carcinoma, the epithelial cells of the projecting and rapidly- 
proliferating endovascular part furnishing the material for the diffuse 
embolic process. 

Etiology. 

Remaining true to the theory that all tumors originate from a matrix 
of embryonic cells of congenital or post-natal origin, we necessarily 
must regard the presence of a matrix of embryonic epithelial cells as 
the essential cause of carcinoma. In the absence of such an essential 
histological basis, no exciting cause or combination of exciting causes 
will result in the production of a carcinoma. The matrix of embryonic 
cells furnishes the essential material for the construction of a carcino- 
matous tumor ; the exciting causes simply set in motion the machinery 
which increases the building material. We took it for granted that 
non-malignant epithelial tumors spring from a similar matrix. The 
question naturally arises, What influences or agencies determine the 
difference in the character of the tumors springing from a similar 
matrix ? Two leading thoughts present themselves in answering this 
question : 1 . The epithelial cells in the matrix of carcinoma are arrested 
in their development and are set aside at an earlier stage, and the prod- 
uct of their tissue-proliferation will therefore be less specialized than 
that of epithelial cells which have reached a higher degree of differen- 
tiation. 2. The environment of a carcinoma-matrix offers less resistance 
to ingrowing of epithelial cells than does that of a papilloma or an 
adenoma. It is more than probable that the matrix of carcinoma is 
composed of cells of a lower degree of differentiation than that of a 
papilloma or an adenoma, and it is almost certain that the conditions 
under which a carcinoma-matrix assumes active tissue-proliferation 
result in a diminution of physiological resistance of the tissues in the 
immediate vicinity of the tumor-matrix. It remains for us to discuss 
more in detail the exciting causes concerned in awakening a dormant 
tissue-matrix to active tissue-proliferation. 

Heredity. — In the majority of cases the tumor-matrix is congenital. 
In the remaining cases it is of post-natal origin, formed in pathological 
products in which some of the young epithelial cells fail to reach 
maturity and are buried in the scar-tissue following the healing of a 



CARCINOMA. 233 

wound or the repair of an inflammatory lesion. Friedreich records a 
case in which a carcinomatous mother gave birth to a child affected by 
carcinoma. A few cases of congenital carcinoma have been reported. 

An hereditary disposition, predisposition, or aptitude, local or gen- 
eral, for carcinoma-growth is generally recognized. It is a difficult 
task to obtain accurate information concerning the frequency with 
which carcinoma occurs in the offspring of carcinomatous parents. 
In this respect statistics as well as many family histories are exceed- 
ingly unreliable. Mr. Cripps wishes to exclude from such statistics all 
cases bearing upon distant relatives, excluding even grandparents. In 
this way he reaches opposite conclusions from those of Sir James Paget, 
who recognizes heredity as a fruitful cause of carcinoma. Figuring on 
the cases from Paget's practice, Mr. Baker makes the statement that 
22.4 per cent, of the cancerous patients were of one or more relatives 
with the same disease. He then gives a table of 103 cases in which 
one or more relatives were affected. These 103 cases representing only 
22.4 per cent, of the total number examined, the whole number must 
have been 460. In these 103 cases, among the relatives are included 
aunts, uncles, first, second, and third cousins, great-aunts, and a great- 
uncle. Among the parents of cancerous patients the death-rate from 
cancer is — (1) According to Paget, 1 in 24.8; (2) according to Baker, 
1 in 22.4 ; (3) according to St. Bartholomew's Hospital, 1 in 28. Accord- 
ing to Mr. Cripps, among the whole community over twenty years of 
age the death-rate is 1 in 29. 

In studying the influence of heredity it is not fair to exclude from 
the statistics distant cancerous relatives, as has been done by Cripps, 
because it is well known that congenital deformities, physiognomy, 
and mental peculiarities frequently reappear several generations apart 
and in distant relatives. There is no reason to doubt that an aptitude 
for cancer is transmitted in a similar manner. In certain families the 
heredity of carcinoma has been shown in a marked manner. Paget 
relates a case in which a lady, two of her daughters, and eight of her 
grandchildren died of carcinoma. A still more marked and far-reaching 
hereditary influence has been referred to in the section on the Etiology 
of Tumors. Lebert relates two cases of colloid carcinoma of the rec- 
tum in which one of the parents in each case was similarly affected. 
To ignore the existence of an hereditary predisposition to carcinoma 
would be to ignore such a predisposition to the acquirement of all 
other pathological processes. 

What such an hereditary predisposition consists of is not known. 
We regard it as a diminution of the physiological resistance of the 
tissues adjacent to the matrix. Such a resistance diminished or abol- 



234 PATHOLOGY AND TREATMENT OF TUMORS. 

ished, the tumor-matrix is no longer held in check, but assumes active 
tissue-proliferation, and the new cells infiltrate the tissues weakened by 
local or general causes. 

Traumatism. — Injuries of various kinds have been regarded from 
time immemorial as a fruitful cause of carcinoma. Without the presence 
of the essential tumor-matrix no amount or kind of injury will produce 
a carcinoma. Injury of a part inhabited by the tumor-matrix will act 
as an exciting cause by diminishing the physiological resistance of the 
tissues adjacent to the matrix. Paget asserts that about one-fifth of 
those who have cancer ascribe it to injury. In some the cancer follows 
almost immediately after the injury; in others it follows as a more 
remote effect. In another and more frequent class of cases repeated 
injuries are necessary to produce this result. 

Billroth maintains that in about 20 per cent, of all cases of carci- 
noma that came under his notice the growth of the tumor could be 
traced to an injury of some kind. Boll's statistics show a traumatic 
origin in 14 per cent., and Cohnheim in 350 cases estimated trauma 
as the principal exciting cause in about 20 per cent. Injuries to plants 
are quite frequently followed by tumor-formation. The immediate cause 
of tumor-growth under such circumstances is attributed by some 
authors (Williams) less to the injury itself than to a change in the 
nutrition of the tissues in the locality. Galls are produced by the 
instillation of the virus of gall-wasps into the tissues of oak-leaves. 
The virus comes in contact with only a few cells, and the new forma- 
tion is due to proliferation of the infected cells. The structure of the 
gall depends more on the kind of vulnerating insect than on the par- 
ticular variety of oak. In the plant buds may form in any place where 
undifferentiated cells are present. The stimulants which determine the 
nutritive flux may be either intrinsic or extrinsic. It is well known 
that in plants injuries frequently result in the formation of a large 
number of adventitious buds. The initial cause of such variations is 
probably to be found in perversions of the secretions of the affected 
part. Injury to a part inhabited by a tumor-matrix alters normal nutri- 
tion, which must result in a diminished physiological resistance of the 
tissues to infective diseases as well as to tumor-growth. 

Physiological resistance is illustrated by allowing one plant out of 
a number to go without water. Insect-stings in the weakly plant 
produce definite changes not produced in well-nourished plants. Local 
influences — and among them we must include trauma — which pervert 
nutrition diminish the physiological resistance of the tissues, and by 
doing so they become an exciting cause of carcinoma. 

Age. — Carcinoma is most prevalent in persons of middle and past 



CARCINOMA. 235 

middle life. The tumor-matrix present at the time of birth or acquired 
later remains in a latent condition until the tissues undergo certain 
changes incident to advanced age, when there are created the local 
conditions necessary to enable the matrix-cells to resume their latent 
vegetative function and to assume active tissue-formation. That these 
senile tissue-changes are something different from ordinal")' marasmus 
caused by disease or by insufficient nourishment becomes evident from 
the fact that persons debilitated by disease or by starvation are not 
more liable to carcinoma than persons of the same age otherwise in 
perfect health. If carcinoma develops in a young person, it is a proof 
that the cells of the tumor-matrix possess more than the ordinary degree 
of vegetative power, or that the person is unduly adapted to cancer- 
formation, or, finally, that the part which contained the tumor-matrix 
has been subjected to influences which produced changes in the tissues 
analogous to those found in the tissues of the aged — in other words, a 
local senility of the tissues. Thiersch has shown that in the lips of 
old people the fibrous tissue wastes away while the glandular tissue 
becomes overgrown, this condition favoring the development of cancer. 

The capacity of a part of the organism to resist a certain amount 
of pressure and still to preserve its histogenetic function will determine 
its vitality. If this power of resistance is lost, then the part becomes 
subject only to passive changes. This is the case for physiological as 
well as for pathological conditions, and as a rule the quantity of paren- 
chymatous fluid is in direct proportion to the capacity of cell-produc- 
tion. This is the case in the skin of elderly persons as far as pertains 
to the stroma. When in this weakened stroma there are present 
organic parts the histogenetic properties of which are still operative, 
those parts will proliferate and lead to a hyperplasia of the epithelial 
tissue which eventually predisposes to the development of carcinoma. 
It may be objected that the abundance of capillaries and their dilatation 
are in opposition to the theory of atrophic condition of the stroma as a 
cause of carcinoma, as claimed by Thiersch. This vascular change is, 
however, only a result of the rarefaction of the connective tissue with 
consequent diminished support against intravascular pressure. 

As the blood furnishes a plasma to the tumor, and likely favors 
development much as a starting plant favors the growth of aphis, it is 
possible that in the aged there may occur blood-changes which favor 
the development of carcinoma. 

Walshe has clearly shown that the mortality from cancer — that is, 
the number of deaths in proportion to the number of persons living — 
" goes on steadily increasing with each succeeding decade until the 
eightieth year." His result is obtained from records of deaths, but it is 



30 


' 40 


4° ' 


' 5o 


5° ' 


' 60 


6o ' 


70 


70 ' 


' 80 



236 PATHOLOGY AND TREATMENT OF TUMORS. 

almost exactly confirmed by the tables collected by Paget showing the 
ages at which the cancers were first observed by the patients or ascer- 
tained by their attendants. 

Paget's Table showing the Influence of Age in the 
Development of Carcinoma. 

Under 10 years 5 per cent. 

Between 10 and 20 years 6.9 

' ; 20 " 30 " 21 

48.5 

100 

"3 

107 

126 

The influence of age in the production of carcinoma is pronounced ; 
the tissue-changes enumerated by Thiersch offer the most plausible 
explanation of this influence, and can be applied with equal propriety 
to carcinoma of all parts of the body as to carcinoma of the lips and 
the skin. 

Climate. — Climate and the attending habits of life and state of 
civilization appear to exert an influence in the causation of carcinoma. 
Walshe collected evidence that the maximum number of carcinoma 
patients are found in Europe, and that carcinoma is very rare among 
the people at Hobart Town and Calcutta and among the natives of 
Egypt, Algiers, Senegal, Arabia, and the tropical parts of America. 
Inquiries that have been made relative to the prevalence of carcinoma 
among the Indians of North America seem to show that they are 
singularly immune to this affection. Few authenticated cases of carci- 
noma have been reported among the Indians unaffected by advancing 
civilization. 

Mental Depression. — A few pathologists have attributed to the ner- 
vous system an important part in the etiology of carcinoma. Mental 
depression has often been quoted as one of the causes in the production 
of carcinoma. While mental anxiety and worry of all kinds may favor 
the origin and growth of carcinoma by impairing nutrition, and thus 
diminishing the physiological resistance of the tissues in the vicinity of 
a tumor-matrix, we have no evidence that nervous influences exert a 
more direct effect in the causation of carcinoma. It is different with 
dread or fear of carcinoma. The writer recollects two patients who for 
no tangible reason whatever were in constant dread of the disease for 
many years, when finally their fears were realized. Apprehensions 
of this nature certainly exert a positive influence in the etiology of 
carcinoma. 



CARCINOMA. 237 

Tuberculosis. — Rokitansky maintained that tuberculosis and car- 
cinoma never existed at the same time in the same person. Other 
investigators have convinced themselves of the incorrectness of this 
assertion. Dittrich states that of one hundred and fifty cases, in only 
one did tuberculosis and carcinoma exist at the same time. Friedreich 
was the first to discover tuberculosis and carcinoma in the same 
organ. Recently there have been reported a number of well-authen- 
ticated cases in which carcinoma developed in tubercular affections 
of the skin. Tubercular lesions prepare the soil for carcinoma, and 
they may even furnish the essential post-natal matrix of embryonic 
cells. 

Prolonged Irritation and Inflammation. — Long-continued local 
irritation is frequently the exciting cause of carcinoma. If the irrita- 
tion is sufficient in intensity to stimulate the mature tissue-cells to pro- 
liferation, it may also furnish a post-natal matrix of embryonic cells, 
and consequently constitute both the essential and exciting causes. 
The frequency with which carcinoma is met with in localities exposed 
to repeated and prolonged irritation points to the fact that the latter is 
often a cause of carcinoma. Carcinoma is frequently found about the 
orifices of the body — the lips, the cervix of the uterus, the rectum, and 
the nose — localities often exposed to irritation. The tobacco-pipe has 
often been quoted as a cause of carcinoma of the lip, but since the 
publication of Melzer's statistics the views on this subject have under- 
gone a change. Carcinoma of the scrotum has been attributed to 
irritation caused by coal-dust: the effect of this source of irritation has, 
however, been over-estimated greatly. Abrasions, punctures of the 
skin, and small wounds have occasionally served as exciting causes. 
Unskilful shaving must also be enumerated as a possible cause. In 
one instance the writer saw a carcinoma develop from a small razor-cut. 
Similarly, insignificant lesions are often referred to as a possible cause 
of carcinoma. Chronic inflammatory lesions of all kinds and the rem- 
nants of acute inflammation have more often been starting-points of 
carcinoma than was formerly supposed or than many are willing to 
admit at the present time. Inflammation not only diminishes the physi- 
ological resistance of the tissues, but its product may also furnish a 
post-natal matrix of embryonic epithelial cells. In a chronic ulcer, for 
instance, young epithelial cells often become buried in the granulation- 
tissue, which may serve as a tumor-matrix, and assume active tissue- 
proliferation at any time when the local conditions are such as to per- 
mit such tumor-formation. The writer has repeatedly seen carcinoma 
develop in scar-tissue or upon the surface of a chronic ulcer. Langen- 
beck observed three cases of lupus in which, after healing of the 



238 PATHOLOGY AND TREATMENT OF TUMORS. 

ulcerated surface, carcinoma developed in the scar-tissue. Similar 
cases have been referred to elsewhere. 

Goodhart has called special attention to irritation as a cause of 
ichthyosis of the tongue and of carcinoma. It has been known for a 
long time that this superficial chronic inflammation of the tongue fre- 
quently precedes carcinoma of this organ. In more than one instance 
carcinoma of the tongue and of the mucous membrane of the cheek 
has been traced to displaced carious teeth and to the sharp margins 
of normal teeth. 

One of the most instructive evidences of the influence of prolonged 
irritation and inflammation in the causation of carcinoma is chronic 
eczema of the nipple, known as " Paget's disease of the nipple." The 
etiological relation of this affection of the nipple to carcinoma of the 
breast was first pointed out by Sir James Paget. Mr. Butlin has cor- 
roborated Paget's views, and has shown that there can be traced struct- 
ural changes extending from the diseased part of the skin along the 
epithelial linings of the gland-ducts in the nipple, and thence along 
their branches into the acini of the carcinomatous part of the gland. 
These acini " become dilated and filled with proliferating epithelium, 
which is at length, so to speak, discharged into the surrounding tissues." 
Paget says: "The cases of cancer thus following eczema are illustra- 
tions of a general rule that a part which lias long been the seat of con- 
stant or often-recurrent inflammation, or, if I may write intentional 
obscurity, of frequent or constant irritation, is apt to become cancerous 
(the italics are the writer's). Similar instances of the rule are observed 
in tongues long affected with psoriasis or ichthyosis, in uteri long or 
often ulcerated, in scars that often 'break out,' in lower lips long 
cracked or excoriated, in warts often irritated, sore, and scabbed, some- 
times in old scrofulous or other ulcers or in sinuses." Paget admits 
that irritation alone and of itself is not enough to produce carcinoma. 
He continues : " It may therefore be deemed very probable that the 
chief or sole effect of irritation is, by inducing a degeneration, to render 
the parts more fit for the invasion of a disease which is essentially of 
an internal origin." 

Paget still adheres to the humoral etiology of carcinoma, but we 
assign, as he does, to chronic irritation and inflammatory products an 
important role in the causation of carcinoma by diminishing the physi- 
ological resistance and by occasionally at least furnishing at the same 
time the essential tumor-matrix of embryonic epithelial cells. 

Another inflammatory product very often the starting-point of car- 
cinoma is the wart. The warts upon the forehead and cheeks of aged 
persons (verruca senilis) most frequently undergo such a transformation. 



CARCINOMA. 239 

The only cases in which the writer has seen primary multiple carcinoma 
were those in which carcinoma had such an origin. The claim might 
be made that these papillomatous swellings were carcinomatous from 
the beginning. Examinations of numerous specimens of this kind have 
furnished pictures showing all stages of transition of an inflammatory 
swelling into a carcinoma, and there can therefore be no doubt of their 
primary inflammatory origin. 

Microbes. — The local, regional, and general dissemination of carci- 
noma is strongly suggestive of the existence of some virus or microbe 
as the prime etiological factor of the origin and dissemination of carci- 
noma. In some respects carcinoma resembles several of the infective 
processes the microbic origin of which has been well established. The 
infectiveness of tuberculosis was recognized a long time before its 
microbic origin was demonstrated. Pathologists have made numerous 
experiments to prove the inoculability of carcinoma. Langenbeck 
injected cancer-juice into the jugular vein of dogs, and it is asserted 
that in one instance the experiment resulted in carcinoma of the lungs. 
Novinsky in 1876, and later Wehr and Hanau, succeeded in inocu- 
lating animals, and Hahn and Bergmann have inoculated the human 
being. 

Carcinoma has frequently been engrafted from one animal into 
another of the same species, and in some instances the experiment 
yielded positive results. The writer has made numerous experiments 
on dogs by implanting carcinoma and sarcoma from man, and the results 
were always negative. A slight induration around the implanted graft 
was all that was ever observed. Induration and graft all disappeared 
by absorption in the course of two or three weeks. The same results 
followed the implantation of malignant grafts from one animal into 
another of the same species. In a recent work Adamkiewicz declares 
that after implantation of a piece of a carcinoma in the brain of a rabbit 
death always took place in about two hours. In the brains thus inocu- 
lated were always found disseminated round-celled metastatic deposits of 
carcinoma which showed a tendency to break down in the centre. The 
carcinoma-cells nearly all disappeared from the engrafted piece, leaving 
only the stroma. Adamkiewicz believes that cancer-cells are living, inde- 
pendent organisms belonging to the class of protozoa. Geissler, who 
repeated the experiments of Adamkiewicz, found that fragments of 
carcinoma-tissue imbedded in the brains of rabbits produced no reaction 
and were absorbed like other aseptic absorbable substances. The views 
of Adamkiewicz regarding the origin of carcinoma are as fallacious as 
the hope he entertained of cancroin as a specific therapeutic agent has 
been shown to be unfounded. The search for a specific microbe dates 



240 PATHOLOGY AND TREATMENT OF TUMORS. 

back to the early days of bacteriology as a science. One of the first 
efforts in this direction was made in 1881 by Wedopil. 

The excitement which Scheuerlen's alleged discovery of a specific 
bacillus of carcinoma produced spread over the world and stimulated 
others to renewed activity in the bacteriological investigation of carci- 
noma. For a short time Scheuerlen's claims were seriously entertained 
and considered, and Schill and Frere went to the trouble to dispute his 
claim to priority of the discovery of the carcinoma bacillus. Later, 
Darier, Wickham, Malassez, Albarran, and Soudakewitsch described 
coccidia-like bodies in tumors. These bodies were studied carefully in 
tumor-tissue by Pfeiffer, Sjobring, Thoma, Podysoski, Delepine, and 
especially by Ruffer. The last author regarded them as psorosperms, 
and he studied their behavior to different kinds of staining material. 
He found them in the protoplasm of cells in all carcinomatous tumors. 
Stroebe, Steinhaus, O. Israel, Karg, Eberth, Ribbert, Hauser, and other 
pathologists entertained more conservative views in regard to the 
etiological importance of these bodies in the causation of tumors. 
Many of these pathologists are of the opinion that the bodies which 
have been described as psorosperms are only the product of cell- 
degeneration. 

The experiments of Ballance and Shattock in the cultivation of 
cancer on nutrient media, and the direct inoculation of cancer per- 
formed by Hanau, Klebs, and others, argue against a microbic origin 
of carcinoma. The sporozoa which have been found in cancer-tissue 
by different observers no doubt play their part in irritation, but there is 
so far no evidence that they are the cause of carcinoma. 

Kurloff considers it very desirable that those engaged in investigating 
the supposed organism of carcinoma should furnish with each published 
case the history of the patient and a clinical and pathologico-anatomical 
account of the tumor. Only by some such plan can we hope to 
systematize the results arrived at by different investigators. Korotneff 
discovered in carcinoma an organism which he called rhopaloccphalns 
canceroniatosus. Kurloff found the same parasite in a vacuole within 
the epithelial cells of a carcinoma of the breast. Ohlmacher of Chicago 
made very extensive investigations concerning the etiological relation 
of sporozoa to carcinoma, and in a recent paper on this subject he 
pointed out that many objects have been described as the parasites 
of carcinoma because the subject has been treated unscientifically. A 
great number of reagents have been used, hence the diversity of results. 
Artificial products are sometimes found by the reagents. It has been 
found that sporozoa treated by different fixing solutions act differently. 
Some agents distort the spores and interfere with the subsequent 



CARCINOMA. 241 

staining. All the present methods of investigation are faulty, and no 
results are to be looked for until new methods are devised. 

To prove the microbic origin of carcinoma it is necessary for bac- 
teriologists to demonstrate the presence of the same organism in every 
carcinomatous tumor. They must isolate the organism and cultivate it 
outside the body upon artificial nutrient media, and zvith pure cidturcs 
they must reproduce the disease in some of the lozi'cr animals. This has 
so far not been done, and until it is done we have no right to claim for 
carcinoma a microbic origin. It has been shown elsewhere that the local 
and general dissemination of carcinoma is effected exclusively by cell- 
metastasis and cell-transportation, and that the secondary and meta- 
static tumors are the exclusive products of tissue-proliferation of cells 
derived from the primary tumor. In all infective swellings the cellular 
elements are derived exclusively from the corpuscular elements of the 
blood and proliferation from pre-existing tissue. Carcinoma-tissue is 
derived exclusively from a matrix of embryonic epithelial cells. The 
pre-existing tissues remain passive in carcinoma as well as in all other 
tumor-formations. 

De Morgan in 1874 said: "I can see no analogy between new 
growth, whether as innocent as lipoma or as malignant as cancer, and 
the products of true general or blood disease. From the first a tumor 
is a living, self-dependent formation, capable of continued growth by 
virtue of its own power of using the nutritive materials supplied to it. 
Nothing like this is seen in any of the blood diseases." Until additional 
and more positive light is shed upon the microbic origin of carcinoma 
we must adhere to the theory that carcinoma is an atypical proliferation 
of cells from a matrix of embryonic epithelial cells of congenital or post- 
natal origin. 

Pathology. 

The most important aberration of the normal growth in carcinoma 
consists in the presence of epithelial cells in vascular connective tissue. 
The epithelial cells retain their vegetative power in the new locality. 
The stroma is derived from the pre-existing connective tissue, and its 
abundance depends largely on the amount of connective tissue in the 
part affected and the intrinsic vegetative capacity of the epithelial cells. 
If the organ affected is dense and fibrous, the pre-existing material for 
the stroma is abundant, and the tumor, at least during its earlier stages, 
will be firm. If the epithelial cells proliferate slowly, the pre-existing 
connective tissue constituting the stroma is increased by the production 
of new connective tissue in response to the stimulation created by the 
carcinoma-cells, which act as an aseptic foreign substance. If the epi- 
thelial cells possess a maximum power of tissue-proliferation, the stroma 
ifi 



242 PATHOLOGY AND TREATMENT OF TUMORS. 

is rapidly broken down, and little or no new connective tissue is formed, 
the resulting tumor grows very rapidly, is soft, and local infection takes 
place early and in a short time becomes diffuse. In hard carcinoma of 
the breast, the so-called " scirrhus," the stroma is abundant and the 
parenchyma is scanty. The same conditions are found in atrophic 
carcinoma and in cancer en adrasse. In the so-called " encephaloid " 
carcinoma the conditions are reversed — a scanty stroma and an abun- 
dance of rapidly-proliferating cells. 

Carcinoma is distinguished from all other tumors by the irregularity 
of its surface and the existence of a wide zone of infiltration. Virchow 
years ago observed a zone of infiltration extending from three to four 
lines from the macroscopical boundary-line of the tumor. Waldeyer 
described this zone as the " inflammatory zone," because he found in 
the connective tissue numerous small cells. This zone often presents 
almost a typical appearance of tissue the seat of a chronic inflamma- 
tion. The infiltration consists of leucocytes and small young epithelial 
cells which, like the leucocytes, wander by virtue of their ameboid 
movements into and along the connective-tissue spaces (Fig. 138). The 



'■0yg£Lr 




"^ 



. &-. 



Fig. 138.— Zone of infiltration around carcinoma ; X 330 (Surgical Clinic, Rush Medical College, Chi- 
cago) : section from near the macroscopical boundary-line of a carcinoma of the abdominal wall : a, young 
epithelial cells infiltrating the stroma, beginning formation of new alveoli; b, stroma; c, wandering leuco- 
cytes. 

infiltration in rapid-growing carcinoma is so extensive that the con- 
nective-tissue spaces are packed with small round cells to such an 
extent as to obscure the stroma completely (Fig. 139, c). 

The leucocytes escape from new imperfect capillary vessels or from 
vessels damaged by the tumor-tissue, and consequently are present in 
great abundance in rapid-growing tumors — a condition which exem- 
plifies the well-known clinical fact that the more closely a carcinomatous 
tumor resembles an inflammatory product, the greater is its malignancy. 
The young epithelial cells possess the maximum capacity to change 
their location by ameboid movements ; hence we find in the zone of 



CARCINOMA. 



243 



■■ii&l'.y-Ji. % 






,_: v u, ,''"/^&.'" iS ' 







Fig. 139. — Extensive ground-cell infiltration at the margin of a carcinoma of the lower jaw ; extension 
of disease from the lip ; X 130: a, carcinoma-cells wandering into site of former pearl ; b, colloid material ; 
c, round-cell infiltration ; d, young carcinoma-cells. 




.-,:j 



• ■■■•iv-'S' - 



wmm 




K^a 



mmmm 










Fig. 140. — Carcinoma of the tongue ; X 85 (Surgical Clinic, Rush Medical College, Chicago) : a, columnar 
projections of carcinoma-cells ; b, epithelial nests ; c, blood-vessels ; d, submucous connective tissue. 



244 



PATHOLOGY AND TREATMENT OF TUMORS. 



infiltration exclusively young epithelial cells which have left the primary 
tumor and are actively engaged in increasing its area. From the sur- 
face of the carcinoma there project into the surrounding tissue tumor- 
masses which render its surface uneven and nodular. These projections 
of the tumor can be seen to greatest advantage in squamous-celled 
carcinoma. They appear first as conical or column-shaped infiltrations 
connected on one side with the primary tumor and projecting into the 
connective tissue on the other (Fig. 140). These projecting parts of 
the tumor impart to it from the very beginning a certain degree of 
immobility and cause the nodulated condition of its surface. 

The stimulation of the tissues caused by the invasion of so many 
foreign bodies results also in the formation of new blood-vessels, 
brought about by a process of budding from the pre-existing blood- 
vessels adjacent to the tumor-matrix. The vascularization, not being 




Fig. 141. — Deep-reaching epithelioma upon the leg, with papillary excrescences. Specimen injected. 
Section from the part of the tumor which occupied the cavity in the tibia ; X 6 (after Thiersch) : a, new 
vessels composed of numerous loops ; 6, elongated pedunculated proliferation of vessels ; c, large vessel- 
trunks which suddenly terminate in capillaries ; if, compact masses of epithelial cells arranged in concentric 
layers, cut transversely or obliquely, and surrounded by vascular stroma ; c , part of a cleft-like cavity con- 
taining epithelial debris ; /, flat polygonal cells in irregular layers, answering to the horny epithelial cells of 
the skin; g, layer of cells representing the rete Malpighii. 

under the normal control of the nervous tissue, and being in a district 
of planless tissue-proliferation, always assumes an atypical type. The 
epithelial cells in carcinoma are brought in direct contact with the new 
blood-vessels (Fig. 141, d). 

The atypical vascularization of a carcinoma exerts a potent influence 
in determining its clinical course. Great vascularity is a prominent 



CARCINOMA. 245 

feature of rapid-growing tumors. In slow-growing hard tumors the 
blood-supply is scanty. In atrophic carcinoma the vessels are com- 
pressed and often obliterated by the cicatricial contraction of the massive 
stroma. Perforation of a vessel-wall by tumor-tissue is apt to be followed 
by metastatic carcinoma or miliary carcinosis. Thrombosis of a prin- 
cipal vessel of the tumor results in speedy and extensive degeneration 
or necrosis of the tumor-tissue. 

Carcinoma-cells retain their embryonic character and never reach 
maturity. The imperfect development of epithelial cells in carcinoma 
is one of the distinctive features between them and the mature epithelial 
cells of benign epithelial tumors. The juvenile condition of the paren- 
chyma-cells of a carcinoma explains the rapid growth of the tumor 
and the early degenerative changes which take place in its tissues. 

Thiersch has well said that the tissue of carcinoma is characterized 
from the start by degeneration. While the degeneration is progressing 
the parts first affected suffer a retrogressive change, without, however, 
it being followed by complete absorption. The pre-existing connective 
tissue is utilized as a temporary scaffolding for the tumor-tissue. The 
parenchyma-cells of all organs affected by carcinoma are subjected to 
pressure, undergo fatty degeneration, and are gradually removed by 
absorption as the tumor advances. The complete removal of glandular 
tissue in secondary carcinoma of the lymphatic glands furnishes a 
striking illustration of the gradual substitution of tumor-tissue for 
the pre-existing glandular structure. The connective tissue of the 
part affected furnishes the stroma of the tumor ; this stroma is increased 
under favorable circumstances, but is likewise subject to degenerative 
changes and to gradual removal by the increasing number of cells. 

The degenerative changes which occur most frequently in carcinoma- 
cells are — 1. Fatty degeneration ; 2. Colloid degeneration; 3. Mucoid 
degeneration. Fatty degeneration begins always „*>?*;*%»„ 

in the centre of the alveoli, in the oldest cells, 

and in the parts most distant from the vascular ^.f ~ i_„ 

supply. The cells in the centre of an epithelial f^f-ff-ff- fi£M-~'' 
nest (Fur- 142) show first in their protoplasm { '.;■ '■Xfl'"^,' f 
granules of fat which increase in size and number 'v';-S ; ^ : ??' 
until the cell breaks up in fragments, leaving '-f^:,".^f 

minute particles of fat and a granular detritus. FlG I42 .I!E P itheiiai pearl 

Fatty degeneration begins at different points in from ardnoml of f in °f c leg; 

J to ° X no, reduced one-fourth (burg- 

the Same alveolus (Fig. 143). ical Clinic, Rush Medical College, 

„, . c c , ... Chicago): a, a, centre of cancer- 

1 he product of fatty degeneration in squa- nesls> showing fatty degeneration 
mous-celled and glandular-celled carcinoma in ° fcells - 
its naked-eye appearances resembles very much the contents of an athe- 



246 



PATHOLOGY AND TREATMENT OF TUMORS. 



roma. It is composed, like the latter, of detached dead and degenerated 

epithelial cells, granules of fat, and a granular detritus. While the centre 

of an alveolus is undergoing this 
change the disease extends in its 
periphery, where cell-proliferation is 
progressing in the outer layer of the 
younger epithelial cells. In ulcer- 
ating carcinoma of the lip and the 
skin the products of fatty degen- 
eration, in the form of small plugs 
presenting the appearance of athe- 
romatous material, can be squeezed 
out upon the surface by pressure. 
The same condition is not met with 
in any other ulcer, and is therefore 
of the greatest diagnostic importance. 
In glandular carcinoma the same 
kind of material can be squeezed 
from the surface on making a sec- 
tion through the tumor. Fatty de- 
generation of the parenchyma of a 
carcinoma is most marked in slow- 
growing hard tumors, and must 

be regarded as a favorable retrogressive change tending to retard the 

growth of the tumor. 




Fig. 143. — Multiple points of fatty degeneration 
in the same alveolus ; X 480 (Surgical Clinic, Rush 
Medical College, Chicago) : a, highly refractile non- 
staining area. 




Fig. 144 — Carcinoma of the rectum with extensive colloid degeneration of the cells lining the tubules 
(after Perls). In the small alveoli, beginning colloid degeneration of the cells ; the larger alveoli are distended 
by colloid material and are without attached cells. 



CARCINOMA. 



247 



Colloid degeneration occurs in the parenchyma and stroma of car- 
cinoma, and is not limited to tumors of any particular type of cells 
( Fl g- 145)- Colloid degeneration of the stroma is found in rapid- 
growing glandular carcinoma. The colloid material is often so abun- 
dant as to obscure the cellular elements and the stroma— so much so 




Fig. 145. — Colloid degeneration of stroma in carcinoma of the mamma ; X 350 (Surgical Clinic, Rush Medical 
College, Chicago) : a, stroma ; b, alveoli packed with epithelial cells ; c, colloid masses in stroma. 



as to induce many authors to regard it as a special form of tumor. 
Lebert showed that what was known as " colloid carcinoma " is a car- 
cinoma modified by the character of the regressive tissue-metamor- 
phosis of its cells or its stroma, or both. Colloid degeneration is of 
very frequent occurrence in carcinoma of the alimentary canal, the 
favorite locality of what was formerly described as " colloid cancer " 
(Fig. 144). 

Mucoid or myxomatous degeneration may occur in either the cells 
or the stroma of a carcinoma. Columnar-celled carcinoma is very apt 
to undergo this form of regressive metamorphosis. It is again the 
oldest cells that first undergo this change. In cylindrical-celled car- 
cinoma, in which the cells are arranged in several layers, the layer next 



248 



PATHOLOGY AND TREATMENT OF TUMORS. 



to the lumen of the tubule is destroyed by the myxomatous process, 
and the mucoid material accumulates in the glandular spaces, forming 
cysts of various sizes (Fig. 146). If the areas of degeneration are 




0' 



Fig. 146. — Cylindrical-celled carcinoma of stomach ; X 250 (after Perls). The cells in the central part of 
the alveoli are destroyed by myxomatous degeneration. 

extensive, the consistence of the tumor varies in different places — a 
matter of importance in diagnosis. Secondary tumors are subject to 
the same degenerative changes as the primary. Ulceration in car- 
cinoma of the skin and the mucous membranes is present almost from 
the beginning. Carcinomatous ulcers of the cutaneous surface are 
usually covered by a crust formed by inspissation of the secretion, 
which crust, if detached, uncovers an ulcer which bleeds upon the 
slightest touch. An ulcer once formed remains permanently , increases 
in size, and manifests no tendency to heal. The differentiation of such 
an ulcer from lupus and from ulcerating syphilitic affections is always 
difficult and sometimes impossible. When the tumor involves the skin 
or when a deep-seated carcinoma has reached the skin, ulceration takes 
place, the central part, being more abundantly supplied with epithelial 
cells and being less vascular, becoming the seat of necrotic changes. 
As soon as the continuity of the surface is destroyed, micro-organisms 
take a part in the subsequent work of destruction, as the tumor-tissue 
becomes the seat of suppurative inflammation. A carcinomatous ulcer 
is characterized by its deep, crater-like cavity, which again may present 
nodules, as well as by its thickened and indurated margins. The ulcer 
may also be flat where the thin infiltrations appear to be destroyed by 
ulceration. These ulcers are always surrounded by steep, abrupt 



CARCINOMA. 249 

margins, and present a flat floor with few or no granulations, being 
thus distinguished from many other kinds of ulcers resulting from 
infective causes. Large ulcers are usually the seat of putrefactive pro- 
cesses and emit an exceedingly offensive odor. The putrefaction is 
caused by the presence of putrefactive bacilli which develop in the 
dead tissue attached to the ulcerated surface. A carcinoma covered 
by normal intact skin may become infected with pyogenic microbes by 
localization in the tumor-tissue of floating microbes. Suppurative 
inflammation of the tumor-tissue under such circumstances is attended 
by the usual symptoms which accompany acute inflammation. Tem- 
perature, rapid pulse, and other symptoms of sepsis, with increase of 
swelling, pain, tenderness, and oedema, are the symptoms to be relied 
upon in ascertaining the existence of this complication. If the tumor 
is large and the infection is extensive, a large part of the tumor may 
slough, leaving a crater-like excavation after the elimination of the 
dead material. 

It will be necessary to add to the general remarks on the pathology 
of carcinoma a brief description of the 

Histological Varieties of Carcinoma. 

Squamous-celled Carcinoma. — This variety of carcinoma develops 
upon the surface of the skin, and is usually described under the term 
" epithelioma." The term " epithelioma " has given rise to a great deal 
of confusion, as some authors describe under it a benign, and others a 
malignant, tumor of the skin or the mucous membranes. The word 
should be abolished in the nomenclature of tumors. 

A squamous-celled carcinoma contains as the essential tumor- 
element squamous or pavement epithelium in imitation of the epithelial 
layers of the skin. The growth usually begins as a small surface 
defect — a crack or fissure of the skin covered by a crust. With the 
cancer-formation the epithelial cells dip down beyond the membrana 
propria into the subcutaneous vascular connective tissue. The tumor 
then is slightly elevated above the level of the surrounding skin, with 
a hard base, and with indurated margins from which infiltrations extend 
into the surrounding tissues. The tumor beneath the skin or under 
the ulcer appears to the palpating finger as a hard mass, almost of the 
density of a piece of cartilage. The tumor ulcerates early, as the oldest 
portion does not receive a blood-supply adequate to nourish its tissues. 
When the epithelial layer is destroyed the connective tissue furnishes 
the surface with a layer of vascular granulations ; but an attempt in 
this direction is only partially successful, as some of the epidermal 
plugs penetrate deeply into the subcutaneous tissue. If these epidermal 



250 PATHOLOGY AND TREATMENT OF TUMORS. 

plugs are carefully examined, their connection with the surface epithelia 
is readily traced by making the section in a right direction : if it is made 
oblique, the deeper parts of the tumor appear disconnected with the 
surface. 

In the proper interpretation of the diagnostic significance of these 
epithelial plugs not only is their net-like branching characteristic, but 
of greater import are their shape and combination. Benign epithelial 
proliferations show the same regular form and arrangement of the cells as 
the normal inversions of the epidermis, and they gradually become nar- 
rower toward the depth, while in the carcinomatous epithelial prolifera- 
tion the nature of the growth is revealed by the irregular arrangement 
of the epithelial cells and their relations to the connective tissue. New 
epithelial cells which form on the surface of granulations in the healing 
of a wound or an ulcer do not possess the power to penetrate into the 
deeper tissues, while penetration of the connective tissue is the most 
conspicuous pathological feature of carcinoma. The carcinoma-cells 
first penetrate the entire thickness of the skin, and later the subcutane- 
ous connective tissue and any other tissue within their reach. Another 
important differential point is that in non-malignant affections of the 
skin the normal shape of the different forms of epithelial cells is main- 
tained, while in carcinoma there is a great similarity in the shape of the 
cells. Epithelial pearls in non-malignant affections appear in the form 
of concentric layers of cells, with the oldest cells in the centre ; in car- 
cinoma the cells of such a pearl are the product of tissue-proliferation 
of a single cell. In carcinoma the cells are often multinuclear, and 
only gradually, by flattening and arrangement in concentric layers, form 
the epithelial nests. 

In ordinary granulation-tissue but few leucocytes are found ; in 
carcinoma they are abundant, especially near capillary vessels. In 
chronic ulcer of the leg, if malignancy sets in, young epithelial cells 
become buried underneath the benign granulations, and a carcinoma of 
considerable size may be produced by them before its presence would 
be recognized by surface indications. If a carcinoma of the skin is 
allowed to run its course undisturbed, regional infection is sure to take 
place, and other complications, in common with glandular carcinoma, 
set in sooner or later, furnishing an abundance of clinical evidence to 
prove the carcinomatous nature of the tumor. 

The favorite localities of squamous-celled carcinoma are the lips, 
the skin of the face, the mouth, the nose, the ear, the penis, the vulva, 
and the anus. In the oesophagus it most frequently attacks that part 
of the tube which lies behind the cricoid cartilage and the bifurcation of 
the trachea. Carcinoma of the tongue commences most frequently at 



CARCINOMA. 251 

the margin and base of the organ, at points irritated by sharp or defect- 
ive teeth. Carcinoma is also quite frequent in the larynx, the vocal cords, 
and, as Stork has observed, from polypoid or papillomatous growths, 
warts, and scars in this organ. The deep, squamous-celled carcinomata 
originate from an incompletely obliterated branchial cleft (Volkmann), 
from remnants of the urachus and of dermoid tumors, or from a dis- 
placed matrix of embryonic cells in any part of the body. Friedlander 
found in the apex of the lung of a phthisical patient a squamous-celled 
carcinoma which projected into a principal bronchus. He believed that 
the columnar cells in this locality had become transformed into squa- 
mous epithelium, and he refers to the observations made by Griffini and 
Ziegler, who found pavement epithelium upon ulcerous, tubercular, and 
syphilitic defects of the trachea. It is, however, more probable that the 
carcinoma had developed from a displaced matrix of epiblastic tissue. 

Erbse saw a case of squamous-celled carcinoma of the lung after 
perforation into the trachea of an cesophagus-carcinoma composed of 
epithelial cells resembling the primary tumor. Klebs thinks that cells 
entered the lung by aspiration before perforation occurred. 

As compared with glandular carcinoma, squamous-celled carcinoma 
pursues a chronic course. This, as we have explained elsewhere, is to 
be attributed not so much to its lesser intrinsic malignancy as to the 
difference in the anatomical location of the two growths. If left to 
itself, squamous-celled carcinoma ultimately presents all the clinical 
features of glandular carcinoma. 

Melanotic carcinoma is a pigmented squamous-celled carcinoma. It 
develops in structures which are pigmented — most frequently in pig- 
mented moles. The pigment appears as granules in the protoplasm of 
the cells. This form of carcinoma is regarded as exceedingly malig- 
nant, giving rise to early and extensive regional infection and to general 
dissemination. The secondary tumors show the same structure, and 
are pigmented like the primary tumor. 

Cylindrical-celled Carcinoma. — The cylindrical-celled carcinoma 
resembles the squamous-celled in so far that it develops upon a free 
surface, but it differs from it in the shape and arrangement of its cells. 
The cells are derived from the hypoblast, are columnar in shape, and 
are attached in single or multiple layers to the inner surface of imper- 
fect tubules. The histological structure of a cylindrical-celled carci- 
noma is an imitation of gland-ducts and of mucous glands of the 
gastro-intestinal canal. The carcinomatous process begins with an 
anomalous vegetation of columnar epithelial cells. The membrana 
propria is defective at points, and permits the cells to escape from the 
tubules into the surrounding connective tissue, where they continue to 



252 PATHOLOGY AND TREATMENT OF TUMORS. 

reproduce themselves by indirect cell-division. The connective tissue 
also proliferates and enters into the formation of the tumor. The dis- 
conuccted development of epithelial cells is an important factor in the 
local extension of the tumor. It marks the first deviation from normal 
growth, and it is always followed by local and regional infection, and, 
as Lebert has shown, very frequently by general dissemination. 

Metastatic tumors, especially of the bones, are often associated with 
a small primary tumor showing greater aptitude for local and general 
dissemination than does squamous-celled carcinoma. The primary 
tumor in such cases has often been overlooked entirely. Klebs 
believes that the extension to bone usually takes place through lymph- 
glands, especially those in the lumbar region. 

Compared with squamous-celled carcinoma, cylindrical-celled carci- 
noma is a much more malignant affection. A partial explanation of 
this difference in their clinical behavior is the presence in the former 
of an abundance of firm connective tissue to serve the purpose of 
stroma, and in the latter of a scanty, loose bed of connective tissue. 
Glandular Carcinoma. — The morphological prototypes of this 
variety of carcinoma in normal tissue are the acinous glands, some 
of which are derived from the epiblast and some from the hypoblast. 
The hard variety of glandular carcinoma has been called "scirrhus" 
for centuries, and this name still figures prominently in our modern 
text-books. The texture of the tumor varies according to the amount 
of stroma present. If the stroma is abundant and firm, the tumor is 
firm — the so-called " scirrhus ;" if the stroma is scanty and the amount 
of tumor-cells is consequently increased, the tumor is soft, constituting 
what was formerly, from its resemblance in consistence and appearance 
to brain-tissue, termed an enccphaloid or medullary cancer. If such 
a tumor ulcerated and fungous masses appeared on the surface of the 
ulcer, which bled easily on being touched, it was called fungus hema- 
todes. Such a distinction between glandular tumors is no longer justi- 
fiable upon histological or clinical grounds, as the same tissue-elements 
are present in all varieties, only in different proportions, and all of these 
varieties result in regional, and frequently in general, infection. The 
classification of carcinoma should be made upon a histological basis, 
and if this is done, all malignant epithelial tumors of acinous glands 
must be brought under one head as glandular carcinoma. 

Glandular carcinoma varies greatly according to the character of the 
mother-soil and the arrangements of its histological elements, but 
many of the features of the varieties formerly regarded as distinct 
types of tumors have so much in common as to constitute a well- 
defined form of carcinoma. The most distinguishing feature between 



ZARCINOMA. 



253 



V; 

;4'T";'M s . :v1t:ji a» 




254 PATHOLOGY AND TREATMENT OF TUMORS. 

glandular carcinoma and carcinoma of the cutaneous and mucous sur- 
faces is that the former gives rise to the formation of a large tumor. 
The reason that a surface carcinoma does not form a large tumor is that 
it can grow in one direction only, and that, being exposed to frequent 
irritation of all kinds, and receiving its blood-supply only from one direc- 
tion, it falls an early prey to ulceration. As soon as a surface carcinoma 
has ulcerated, the tumor-tissue is exposed to infection -with pathogenic 
microbes, which infection, by producing a suppurative inflammation, aids 
in the destruction of tumor-tissue. A glandular carcinoma is better pro- 
tected against irritation, injury, and infection with pathogenic microbes, 
is surrounded everywhere by tissue, and receives its blood-supply from 
all sides, and it is for these reasons that the tumor attains larger size 
and that ulceration sets in later than in a surface carcinoma. 

Carcinoma of the breast is the most familiar representative of the 
glandular group. In the hard glandular tumor the epithelial cells lose 
their typical shape sooner than in the soft variety, owing to the pres- 
sure to which they are subjected on the part of the massive stroma 
and to the scanty blood-supply. The defective acinous grouping of 
the epithelial cells (Fig. 147) points to a deeper nutritive disturbance 
than is the case in adenoma (Fig. 148), and should always be looked 
for in making a differential diagnosis by the aid of the microscope. 
The carcinomatous character of the tumor becomes evident when the 
tissues adjacent to the tumor are examined. If the tumor, for instance, 
is surrounded by fat, this tissue will be found infiltrated with new 
epithelial cells, and hence what might have been considered macro- 
scopically as the most important features, adhesion and infiltration, 
become corroborated by examination of these tissues under the micro- 
scope. When the tumor starts in the acini of the gland — or, rather, when 
the tumor presents an acinous structure — the picture is entirely changed, 
as the histological arrangement in a hard glandular tumor presents no 
resemblance whatever to normal gland-tissue : the glandular tissue has 
given way to a firm, quite homogeneous, fibrous mass ; only numerous, 
narrow, somewhat deeply-stained stripes indicate the location of the 
compressed, proliferating epithelial cells. The carcinomatous tissue pre- 
sents a peculiarly distinctive histological type. This tissue consists of a 
mixture of epithelial cells and connective tissue, the mutual topographical 
and numerical relations of which deviate completely from the normal 
structure of the mammary gland. 

The highest degree of atypical tissue-proliferation is met with in 
carcinoma of the mammary gland. The local infection extends along 
pre-existing connective-tissue spaces, and ultimately extends beyond 
the limits of the gland to the overlying skin and the wall of the thorax, 



CARCINOMA. 255 

which is frequently perforated by the growth, either by continuity of 
growth and successive involvement of the different tissues, or in the 
course of the lymphatics until the pleura is reached, when the disease 
spreads rapidly over the serous surfaces, usually resulting in hydro- 
thorax. The serum in such cases is frequently stained by the admix- 
ture of blood. Glandular carcinoma is followed at an early stage 
by regional infection. The lymphatic glands nearest the organ affected 
in the direction of the lymph-current, are usually involved first, when 
step by step, successive glands are implicated until the entire chain of 
glands has become infected. General infection at this stage may occui 
at any time and may hasten the death of the patient. The gland. 5 
most frequently the seat of carcinoma are the mammary, thyroid 
parotid, submaxillary, ovary, testicle, kidneys, pancreas, and prostate. 

Diagnosis. 
The difficulty in the diagnosis of carcinoma depends on the size anc 
location of the tumor. In advanced carcinoma of the external parts 
of the body a correct diagnosis can often be made on first sight. The 
diagnosis of carcinoma of internal organs is frequently made only ir 
the post-mortem room. The successful treatment of carcinoms 
depends upon an early and a correct diagnosis and prompt anc 
thorough operative interference. The early diagnosis requires a care- 
ful study of the clinical history of the case, supplemented by z 
thorough examination of the tumor, and followed by a critical analysis 
of the signs and symptoms presented. In doubtful cases a correct 
diagnosis is possible only by differentiating from a supposed carcinoma 
swellings and tumors which simulate it — that is, by exclusion. Inoc- 
ulation experiments and the use of the microscope may become neces- 
sary to make a differential diagnosis between carcinoma and some of 
the infective swellings. In obtaining the clinical history it is importanl 
to inquire into the family history in reference to the possible existence 
of an hereditary predisposition to carcinoma. To elicit information of 
value concerning this point it is necessary to trace back the familj 
history for two or three generations, because such an hereditary predis- 
position does not necessarily occur in the immediate offspring of car- 
cinomatous parents, but may appear in the second, third, or fourtr 
generation. The writer knows of one family in which both parent; 
died of carcinoma — the husband of carcinoma of the stomach, the 
wife of carcinoma of the uterus — and yet the children, one of whorr 
has now reached his sixtieth year, have shown no symptoms of this 
disease. In tracing the family history in the cases of carcinoma thai 
have come under his observation the writer has had patients tell hirr 



256 PATHOLOGY AND TREATMENT OF TUMORS. 

repeatedly that one of the grandparents or great-grandparents died of 
carcinoma. It is also important to elicit the existence of malignant 
disease among more distant relatives, as the hereditary predisposition 
may follow with varying degrees of intensity different branches of the 
same family. 

The age of the patient is an important element in the diagnosis of 
doubtful tumors. Carcinoma is a disease that in preference attacks 
persons of middle or past middle life. The aptitude for this disease 
increases after middle life. In very rare instances it has been of con- 
genital origin or has developed during childhood. It is quite rare in 
persons less than twenty years of age, and is more common during the 
third decade of life. The writer has seen carcinoma of the rectum in 
a boy eighteen years of age, carcinoma of the breast in a girl twenty- 
five years old, carcinoma of the lower lip in a man twenty-seven 
years old, and carcinoma of the stomach in a man of thirty. Cases 
of carcinoma in persons less than thirty years of age are, however, 
extremely rare. A tumor of the lip occurring in a man less than thirty 
years of age is in all probability anything else than a carcinoma, while 
in persons past middle life the probability of its being carcinomatous is 
greatly increased. If a woman less than thirty years of age is suffering 
from pelvic distress, menorrhagia, and profuse leucorrhceal discharge, 
the probability of these symptoms being caused by carcinoma of the 
uterus is exceedingly small, while the same complexus of symptoms 
occurring in a woman at the time of the menopause or later points 
strongly in that direction. A solid tumor in females less than twenty- 
five years of age is usually of a benign nature, while its appearance in 
women past thirty years of age should arouse a strong suspicion of 
its malignant character. 

Sex exerts a strong influence in determining the location of carci- 
noma. Pyloric obstruction of the stomach is caused by carcinoma 
much more frequently in men than in women. Carcinoma of the lip is 
extremely rare in women. Carcinoma of the breast in the male is an 
exceptional occurrence. Carcinoma of the genital organs is much more 
frequent in women than in men. 

Rapidity of growth is a marked feature of carcinoma as compared 
with benign tumors. A rapid-growing tumor is therefore more apt 
to be mistaken for an inflammatory swelling than for a carcinoma. 
Rapidity of growth as a diagnostic evidence, however, must be weighed 
carefully before conclusions are drawn from it, otherwise the surgeon 
is very likely to be misled. A carcinoma may remain latent for many 
years before manifesting malignant qualities. An inflammatory swell- 
ing, as a rule, increases in size more rapidly than a carcinoma. Patients 



CARCINOMA. 257 

have been sent to the writer repeatedly with the diagnosis of carcinoma 
of the breast, when the clinical history showed that the swelling had 
reached its maximum size in from four to six weeks — the result of 
an almost painless subacute suppurative inflammation of the breast. 
In rapidly-growing tumors particular pains should be taken to ascertain 
a possible source of infection. If, for instance, a tumor of the testicle 
attains the size of a hen's egg in a few weeks in a man more than thirty 
years of age, a suspicion of syphilitic infection should be excited. A 
gumma of the testicle will increase in size much more rapidly than a 
carcinoma of the same organ. A rapid-growing carcinoma must be 
differentiated carefully from infective swellings of all kinds — gumma, 
tuberculosis, actinomycosis, and chronic suppuration. 

Tenderness and pain, although present to a more or less marked 
degree in advanced carcinoma, are symptoms of greater prominence in 
inflammatory affections. Non-professional men and women have an 
exaggerated idea of pain as a symptom of carcinoma. They are im- 
pressed with the belief, handed down for ages, that carcinoma is an 
exceedingly painful affection, and it is difficult to make them under- 
stand that carcinoma may occur as a painless affection. Carcinomata 
of the skin and mucous membranes are not attended by much pain. 
Patients who have suffered perhaps for a year or more from carcinoma 
of the rectum generally complain of but little pain, and seek medical 
advice for what they have regarded all along as piles. Carcinoma of 
the stomach is a comparatively painless affection, and the suffering 
caused by it is more from the mechanical obstruction than from the 
carcinoma per se. The temporaiy sharp, shooting, lightning pains so 
frequently described as a characteristic symptom of carcinoma are often 
entirely absent and are always of an intermittent character. The writer 
has frequently opened the abdomen for acute intestinal obstruction, and 
has found carcinoma of the intestine without the patient's having known 
that there was anything seriously wrong before the symptoms of acute 
obstruction set in. 

Tenderness, a symptom of the greatest diagnostic importance in 
inflammatory affections, is usually entirely wanting in uncomplicated 
carcinoma. Dilatation of the superficial veins is the result of great 
vascularity or of deep-seated venous obstruction, and is present as fre- 
quently in infective swellings as in carcinoma. Redness is present in 
carcinoma when the tumor has reached and implicated the skin and 
is on the verge of ulceration. It is only under similar circumstances 
that it is present in infective swellings. (Edema, so significant of the 
presence of a deep-seated abscess, is present in carcinoma when the 
regional infection interferes with the lymphatic or venous circulation 
17 



258 PATHOLOGY AND TREATMENT OF TUMORS. 

or when the tumor has become the seat of infection with pus-mi- 
crobes. 

Primary multiplicity of the tumor seldom occurs in carcinoma, but 
is of frequent occurrence in the case of benign epiblastic, hypoblastic, 
and mesoblastic tumors. Carcinoma as a multiple affection is occa- 
sionally met with in the aged, when the disease originates by the trans- 
formation of senile warts into carcinoma. Cases of primary multiple 
carcinoma have been reported by Liicke, Winiwarter, Klebs, and Kauf- 
mann. Recently there came under the observation of the writer a case 
in which four carcinomata of the face developed almost simultaneously. 
One tumor occupied the malar region on the left side ; another, the 
lobe of the left ear ; a third was situated over the angle of the lower 
jaw ; and the fourth was a typical ulcerating carcinoma of the lower 
lip that had given rise to infection of the submental and submaxillary 
glands. 

Benign tumors are always encapsulated, hence, unless bound down 
by surrounding tissues, are movable and have well-defined margins. 
Carcinoma is an infiltrating tumor, and has abrupt, well-defined mar- 
gins. The infiltration gives rise to nodulation of its surface and to 
immobility of the tumor. A nodulated fixed tumor is in all probability 
a carcinoma. To test the mobility of the tumor it should be palpated 
carefully between the two index fingers to ascertain the points of fixa- 
tion caused by the infiltration. An adenoma of the breast will slip 
between the fingers, while a carcinoma of the same size will be more 
or less fixed in its location by the peripheral parts of the tumor which 
project into the surrounding tissues. 

Hardness of the tumor is usually recognized as a sign of malig- 
nancy. A fibro-adenoma could not be differentiated from a carcinoma 
by this sign. A carcinoma with a scanty reticulum and extensive de- 
generative changes is a soft tumor, resembling in this respect an 
adenoma with cystic degeneration. The diagnostic importance of this 
property of carcinoma has been overestimated greatly. 

Fluctuation, when too much relied upon, leads to frequent mistakes 
in diagnosis and treatment. It is present in cystoma, cystic adenoma, 
and inflammatory swellings with central softening, as well as in soft 
carcinoma with extensive regressive degeneration of the centre of the 
tumor. Psctido-fljtctuation is often present in soft carcinoma without 
cystic degeneration. This sign has often induced surgeons to puncture 
a malignant carcinoma under the belief that they were opening an 
abscess. Such mistakes, in addition to being a source of mortifica- 
tion to the surgeon, have always resulted disastrously to the patient 
by transforming a subcutaneous into an open carcinoma, with all the 



CARCINOMA. 259 

annoyances and dangers incident to such a change. A suspicious fluctu- 
ating swelling should never be punctured or incised without having ex- 
cluded the existence of a soft carcinoma, sarcoma, or granuloma by the 
use of the exploratory syringe. 

One of the important steps in the diagnosis of a carcinoma is the 
examination of the lymphatic glands. In suspected carcinoma of the 
lip, the submental and submaxillary glands ; in tumors of the mam- 
mary gland, the glands of the axilla ; in ulcerative affections of the 
cervix of the uterus, the sacral glands, — should be examined carefully. 
Many conclusions have frequently been drawn from the results of such 
an examination. In tumors of the breast a diagnosis of their benign 
nature has often been based upon the absence of palpable lymphatic 
glands in the axilla. Some excellent modern authorities continue to 
advise, when no enlarged glands can be felt in the axilla, that this 
region should not be invaded in operations for carcinoma of the mam- 
mary gland. This is teaching of a dangerous kind. The writer has 
frequently failed to find any evidences of regional infection by examina- 
tion through the intact skin in cases of carcinoma of the breast, when 
during the operation, upon exposing the deep lymphatics of the axilla 
by free incision, numerous glands the size of a marble were found. In 
obese women it is impossible by external palpation to detect glands the size 
of a pea or even that of a marble, and consequently such an examination 
cannot be relied upon in determining the extent of the operation before- 
hand. Carcinoma of the skin does not give rise to early regional infec- 
tion, and yet when the disease has become quite extensive exposure 
of the submental and submaxillary glands by a free incision frequently 
reveals the presence of glands, as large as a pea, which could not be 
felt through the intact skin. Examination of the retroperitoneal lym- 
phatic glands in suspected cases of carcinoma of the uterus should 
never be neelected. In carcinoma of the skin of the extremities the 
glands in the different regions should be subjected to a scrutinizing 
examination. Enlarged glands under such circumstances have often 
been overlooked, and such oversights have been responsible for many 
disappointing results. Enlargement of lymphatic glands in the region 
occupied bv the tumor, without ulceration of the surface and without 
involvement of the glatids in other regions, is almost positive proof of 
the carcinomatous nature of the tumor. Enlargement of the lymphatic 
glands in the region occupied by an ulcerating tumor may be the result 
of infection of the lymphatic glands, in which case pathogenic microbes 
have entered the lymphatic channels through the surface defect. In lymph- 
adenitis the glands are not so hard as in secondary carcinoma of the 
lymphatic glands, and are more tender on pressure. In ulcerating car- 



260 PATHOLOGY AND TREATMENT OF TUMORS. 

cinoma the lymphatic glands in the region occupied by the tumor may 
be the seat of both microbic infection and cell-metastasis, when the local 
signs and symptoms correspond with this double infection. If from 
other evidences a diagnosis of ulcerating carcinoma can be made, the 
lymphatic glands should be subjected to treatment as though their enlarge- 
ment were exclusively due to cellular infection. Universal lymphatic 
hyperplasia is one of the most important indications of syphilitic infection, 
and a tumor occurring in a person showing such a condition should be 
examined with the utmost care, to exclude the possibility of its being a 
gumma. 

The greatest difficulties are encountered in the diagnosis of ulcer- 
ating tumors. It is in such cases that it is so important to ascertain 
from the patient's statements the probable starting-point of the tumor. 
Epithelial tumors, with few exceptions, start in the tissues derived from 
the epiblast or the hypoblast — that is, in the skin, the mucous mem- 
brane, or the glandular tissue. If the tumor developed in the skin or 
the mucous membrane, it appeared first as a surface tumor, and could 
be moved only by moving the skin or the mucous membrane in which 
it originated ; that is, it was in the beginning superficial and not covered 
by skin or by mucous membrane. If it developed in an acinous gland, 
it could be moved with the gland and was covered by skin or by 
mucous membrane. All mesoblastic tumors start as subcutaneous or sub- 
mucous tumors. Infective swellings seldom appear primarily as surface 
lesions. If they occur as lesions of the skin or the mucous mem- 
brane, the incipient swellings appeared as nodules covered by skin or 
by mucous membrane. If they originated in the connective tissue 
more distant from the skin, as is more frequently the case, the skin 
or the mucous membrane became involved later as the infection 
extended toward the surface. 

The lesions most frequently mistaken for ulcerating carcinoma 
of the skin are tuberculosis, syphilis, actinomycosis, and chronic 
ulcers of the leg. The greatest diagnostic doubts arise in connection 
with ulcerating affections of the nose, face, lips, tongue, and cervix 
uteri. It will interest the student to know that primaty syphilis of the 
lip, tonsil, and vulva has repeatedly been mistaken for carcinoma. Such 
inflammatory swellings have been excised, and a correct diagnosis was 
only made, if the physician was honest enough to admit his mistake, 
after the appearance of secondary symptoms. In chancre the swelling 
appears rapidly upon the expiration of the usual period of incubation, 
and gives rise to regional infection of the lymphatic glands soon 
after the appearance of the first symptoms of local infection. Gland- 
ular infection is unusually severe and extensive in chancre of the lip. 



CARCINOMA. 261 

Tuberculosis of the nose attacks in preference the alae, while syphilis 
attacks most frequently the septum. Carcinoma starts most frequently 
at the junction of the skin with the mucous membrane. 

Tubercular and syphilitic ulcers often heal wholly or in part spon- 
tanously or under proper local and general treatment. Carcinomatous 
ulceration may remain stationary for a long time, but never heals, and 
assumes sooner or later a progressive character. Syphilitic ulceration 
is preceded by gummatous infiltration, and examination of the whole 
body will usually reveal the marks of antecedent syphilitic lesions or the 
existence of such in other parts of the body, and among them hyper- 
plasia of the lymphatic glands in the different regions, notably the post- 
cervical and cubital glands. With few exceptions carcinoma appears as 
an isolated affection, while syphilitic and tubercular ulcers often occur 
as a multiple lesion. Regional infection through the lymphatics is sel- 
dom present in tuberculosis and syphilis, but is a frequent complication 
in advanced cases of carcinoma of the skin. Actinomycosis seldom 
presents itself to the surgeon except as a swelling connected with the 
maxillary bones, where it simulates sarcoma more closely than carci- 
noma. The discovery of actinomyces by the aid of the microscope, or 
the discovery of the fungus by the naked eye in the secretions as minute 
yellowish-gray particles, will settle the diagnosis. Sections taken from 
the margins of the ulcer in carcinoma will reveal the characteristic 
typical structure of the tumor, while the tissues from all infective swell- 
ings will exhibit the typical structure of granulomata. If the micro- 
scope is inadequate to make a positive diagnosis, inoculation experi- 
ments will shed additional light and dispel doubt. Implantation of 
carcinoma-tissue and of tissue from a gumma in guinea-pigs and rab- 
bits will yield a negative result, while inoculation with tubercular tissue 
will reproduce the disease in the animal. 

The diagnosis of carcinoma of internal organs must often be based 
almost exclusively upon the functional disturbances produced by the 
tumor. A circular constricting carcinoma of the pyloric end of the 
stomach often eludes detection by external examination during the 
lifetime of the patient, but the symptoms produced by pyloric stenosis 
in men more than thirty years old strongly suggest as the mechanical 
obstruction a malignant tumor. Progressive intestinal stenosis in per- 
sons advanced in years points in the same direction. In aged men 
hematuria not caused by stone in the bladder indicates the probable 
existence of carcinoma of this organ. CEsophageal obstruction in per- 
sons past middle life is in the great majority of cases caused by carci- 
noma* In the absence of urgent indications for prompt operative inter- 
ference the clinical history of the tumor should be followed carefully. 



262 



PATHOLOGY AND TREATMENT OF TUMORS. 



The rapidity of its growth and its extension to tissues irrespective of 
their anatomical structure should be noted carefully, and the micro- 
scope should be made use of as a diagnostic aid. 

The first indication of the malignant nature of an epithelial tumor 
is cell-metastasis, upon which depends the local infection. In non- 
malignant epithelial tumors the normal relations between the epithelial 
cells and the membrana propria are preserved. The epithelial cells 
may be increased greatly in number, the layers increased in number, 



7~^ — 



.'J. '.'!■,',' J. i. 1 J 1 .' , r .l , L. . 







■' 

ft, , ■■ ~ ■ "■* " ■ " ' -■' ^ !" ■ - 

to --.. . - 






Fig. 149. — Fibroadenoma of the breast, showing the epithelial cells lining the duct greatly increased 
in number, but in their normal anatomical locations (Surgical Clinic, Rush Medical College, Chicago) : 
a, massive stroma of fibrous tissue free from epithelial infiltration ; b t tubule cut longitudinally, lined by 
several layers of epithelial cells. 



and the cells closely packed and irregularly arranged, but the mem- 
brana propria remains as an impermeable wall (Fig. 149). 

The most reliable evidence of the malignant nature of the tissues 
shown on Plate 4 is the infiltration by epithelial cells of the adipose 
tissue adjacent to the tumor. Normal adipose tissue does not con- 
tain epithelial cells : their presence in it could have occurred only by 
migration from a carcinomatous tumor in its vicinity. The presence of 
young proliferating epithelial cells in any of the incsoblastic tissues is an 
unmistakable evidence of carcinoma. In making- a diagnosis of carci- 
noma under the microscope we search for the presence of epithelial 
cells in mesoblastic tissues, and when we find epithelial cells anywhere 
in vascular connective tissue in a state of proliferation, the diagnosis of 
carcinoma can be made with certainty. The student must make him- 
self perfectly familiar with the morphological appearance of the different 
kinds of epithelial cells under different circumstances, so that he will be 



CARCINOMA. 



Plate 4. 




<M 



Tubular carcinoma of mamma (after Klebs) : a, milk-duct with hyaline contents; b, proliferating gland- 
tissue ; c, group o( acini, showing tissue-changes; d, adipose tissue with groups of epithelial cells near the 
tumor-tissue : the cells are not arranged in the form of acini. (Obj. 4, oc. 2.) 



CARCINOMA. 263 

able to distinguish them at a glance from other histological elements. 
J he absence of epithelial cells in abnormal localities in a section from a 
suspicious tumor is no proof of the non-malignant nature of the tumor. 
The section may have been taken from a part of the tumor devoid of 
carcinomatous tissue. If the microscope is to be relied upon as a 
diagnostic resource in the examination of a tumor, the sections must 
be taken from parts of the tumor where the growth is most manifest. 
Carcinoma grows by infiltration : the specimen to be examined should 
therefore be taken from the base or the periphery of the tumor, near 
its macroscopical boundary-line. If the first section under the micro- 
scope presents negative evidence, sections from different parts of the 
tumor must be examined in order to prove either its malignant or its 
benign character. In ulcerating surface carcinoma a fragment of tissue 
should be clipped with scissors from the indurated margin. In papillary 
excrescences a papilla is removed and examined. In deep-seated 
tumors Warren's harpoon is employed in obtaining the material for 
microscopic examination. From fragments of tissue thus obtained 
several sections are made and examined. The products of scraping or 
teasing preparations should not be used for the purpose of making a 
diagnosis by the aid of the microscope. 

Prognosis. 
The prognosis of carcinoma is greatly influenced by the histological 
structure and the location of the tumor. Squamous-celled carcinoma 
is a much more chronic affection than cylindrical- and glandular-celled 
carcinoma. The location of a carcinoma influences the prognosis in 
two ways : (1) If the carcinoma is located on an exposed part of the 
surface of the body, the patient is soon made aware of its existence ; 
his friends discover the tumor and remind him constantly of its presence, 
inducing the patient to seek, timely medical advice. A tumor thus 
located is accessible to a radical operation. (2) In carcinoma of the 
internal organs the tumor, as a rule, is not discovered by the patient or 
his physician until extensive regional infection has made its complete 
removal impossible. A carcinoma of the breast is often only discovered 
accidentally after the axillary glands have become extensively involved. 
A patient suffering from carcinoma of the stomach is usually treated for 
indigestion, dyspepsia, or catarrh of the stomach for weeks and months 
until the clinical course has demonstrated the malignant nature of the 
affection long after the disease has passed beyond the reach of a radical 
operation. Examination of the stomach and the adjacent organs, 
including the retroperitoneal lymphatic glands, in the writer's fifteen 
cases of gastro-enterostomy revealed regional infection beyond the 



264 PATHOLOGY AND TREATMENT OF TUMORS. 

limits of a radical operation in all but one case, and in this case the 
patient had been reduced to a skeleton by the pyloric obstruction 
caused by a constricting circular carcinoma. 

Women suffering from carcinoma of the uterus console themselves 
for months with the thought that they are undergoing the ailments 
incident to the menopause before they seek medical advice ; and when 
this is finally done, in more than two-thirds of all the cases the disease 
has passed far beyond the limits of a successful radical operation. In 
the writer's practice less than 25 per cent, of the cases of carcinoma of 
the uterus were found within the justifiable limits of a radical operation. 
The prognosis in operable cases of carcinoma must therefore largely rest 
upon the location of the tumor and the extent and accessibility of the 
regional infection. 

If the carcinoma involves a part or an organ inaccessible to operative 
interference — as the pancreas, for instance — the disease will pursue its 
typical course uninfluenced by treatment, and in the course of a year 
or two will result in the death of the patient. In carcinoma of the 
kidney this disease has usually progressed beyond the reach of a suc- 
cessful operation before its true nature is recognized. Such early 
operations as Israel's, in which the tumor was not larger than a cherry, 
would of course promise a permanent result, but diagnosis at such an 
early stage is possible only in the hands of expert diagnosticians, and 
will always be considered as an evidence of special skill and training. 

The greatest progress in the treatment of carcinoma will have been 
made when wc are placed in possession of an infallible means of early 
diagnosis. The extent of the regional infection and the accessibility of 
the secondary tumors to operative treatment will also greatly modify 
the results to be expected from operative treatment. Even extensive 
regional infection of the axilla in cases of carcinoma does not preclude 
the possibility of a radical cure. On the contraiy, limited axillary 
infection with enlargement of the lymphatic glands in the supraclavic- 
ular region is an evidence that the disease has passed beyond the reach 
of a successful operation. The appearance of a metastatic tumor or 
a miliary carcinosis seals the fate of the patient and furnishes a positive 
contraindication to local treatment with a view of removing the primary 
tumor. The average duration of life in carcinoma permitted to follow 
its own course is from two to three years. Death finally results from 
metastasis, septic infection, or exhaustion when the primary or any of 
the secondary tumors interfere with an important physiological func- 
tion. Favorable indications, so far as the primary tumor is concerned, 
are hardness, slow growth, and its location in an organ not essential to 
the maintenance of life. Unfavorable conditions are rapid growth and 



CARCINOMA. 265 

softness of the tumor. The more a carcinoma resembles in its local 
behavior an inflammatory process, the greater is its malignancy and 
the greater the immediate danger to life. The writer has come to 
regard rapid-growing secondary tumors of the lymphatic glands, re- 
sembling in their physical properties and clinical aspects suppurative 
lymphangitis, as a noli-me-tangere. From a prognostic standpoint, 
imperfect removal of the primary tumor by caustics or by the use of 
the knife must be regarded as a measure calculated to aggravate the 
local conditions and to shorten life. Carcinoma grows much more 
rapidly, and terminates fatally sooner, in young than in old persons. 
As a rule, the malignancy of carcinoma is in an inverse ratio to the 
age of the patient. 

Treatment. 

Every modern writer on carcinoma insists upon the importance of 
early operative treatment. Carcinoma is no longer regarded as a con- 
stitutional or blood disease. It has a benign stage, during which it 
resembles benign epithelial tumors, and it is amenable to successful 
treatment by thorough removal. Every surgeon knows that complete 
removal by excision of a carcinoma of the lip during its early stages 
is seldom followed by local or regional recurrence, and that the opera- 
tion furnishes almost certain protection against general dissemination. 
What is possible in these cases is within the reach of successful surgery 
in the case of cylindrical-celled and glandular carcinoma, provided the 
operation is performed with the same thoroughness and under similar 
favorable conditions. In fact, the writer is of the opinion that the 
removal of the entire breast at a time when the disease is still local, 
and the extirpation of the uterus at a time when the disease remains 
limited to the cervical canal, would yield as satisfactoiy results as 
does early excision of carcinoma of the lip. The removal of an 
entire organ for carcinoma at an early stage of the disease can hardly 
fail in removing the zone of local infection. What surgery has to con- 
tend with is late operation. The writer is an ardent advocate of all 
legitimate attempts to eradicate carcinoma by operation, but is satisfied 
that the furor operatives has been carried too far at the present time in 
this department of surgery as well as in nearly all others. 

The successful treatment of carcinoma requires a bold surgeon. A 
good and safe surgeon is guided by prudence and good judgment in 
the selection of his cases. Like a good general, he looks over the 
whole ground and estimates carefully the strength of his enemy before 
making an attack. The surgeon is too apt to look only upon the 
tumor, and to ignore the patient, when he decides upon the propriety 



266 PATHOLOGY AND TREATMENT OF TUMORS. 

of an operation. A remunerative fee or the fear that the patient might 
get into the hands of his competitors often deadens his sense of 
moral obligation toward his patient when he renders his final judgment 
concerning the propriety of an operation. For the welfare of the pa- 
tient, the reputation of the surgeon, and the honor and good standing 
of the profession it is just as important to look for contraindications to, 
as for indications for, a radical operation. That the treatment of carci- 
noma has been marred by many sins of omission and of commission in 
the hands of competent surgeons goes without saying. The tempta- 
tions to carry operative procedures to their maximum limits, and beyond, 
are greater in the treatment of carcinoma than in any other department 
of surgery. We find patients suffering from incipient carcinoma often 
averse to the use of the knife, but willing to lose their lives on the 
operating-table in attempts to secure relief when the disease has passed 
far beyond the limits of successful surgery. It requires moral courage 
to refuse an operation when such a patient begs his surgeon to perform 
it and is willing to shoulder all risks and responsibilities. The surgeon 
has no moral right to become a legitimate executioner under any circum- 
stances. 

A radical operation is contraindicated by — i. Extreme senile maras- 
mus ; 2. Extensive local infection ; 3. Regional infection beyond the 
reach of complete removal of all the infected tissues ; 4. General infec- 
tion ; 5. The coexistence of another disease which in itself will prove 
fatal in a short time. 

It is difficult to set a limit by age to the operative treatment of car- 
cinoma. The writer has removed successfully from the temporal region, 
in a lady eighty-five years of age, under partial anesthesia, a fungous 
carcinoma the size of a large orange. The large wound granulated in 
the course of two weeks, and healed by the aid of Thiersch's skin-grafts 
four weeks after the operation. The writer has seen patients not more 
than fifty years of age so marantic from senile degenerations that the 
smallest wound would probably have failed to heal. In persons past 
seventy years of age suffering from a slowly-growing carcinoma in a 
locality requiring a formidable operation it requires good judgment to 
decide whether an operation will benefit the patient or whether it will 
shorten life. It is in such cases that the extent of the operation must 
be planned carefully and the patient's strength be estimated before an 
operation is advised. If the local infection has extended so far that 
there is no prospect of healing the wound by plastic operations or by 
skin-grafting after the removal of the primary tumor, the patient's 
interests demand conservative treatment. Usually in such cases the 
tumor has so far infiltrated the deep tissues that a complete removal 



CARCINOMA. 267 

of all the infected tissues is impossible, and the wound-surface soon 
becomes the seat of a diffuse local return attended by conditions much 
more annoying and disagreeable to the patient than the primary 
tumor. It is the regional infection that renders the results of opera- 
tions so problematical in the treatment of carcinoma. Every honest 
surgeon must confess that the permanent results of operations per- 
formed after regional infection had occurred are few and far apart. The 
disease may not return for one, two, or three years, but return it will, in 
the great majority of cases, sooner or later. The writer has seen local 
recurrence five and seven years after operation. The time set usually — 
three years — is therefore not reliable in drawing conclusions as to the 
permanency of the result after operations for carcinoma. Permanent 
results will follow the operative treatment of carcinoma if the operation is 
performed before regional infection lias occurred ; on the contrary, non- 
recurrence will be the exception, and recurrence the ride, if the primary 
tumor is not removed until regional infection has set in. If the regional 
infection is extensive, or if it occupies a locality not accessible to thor- 
ough removal of all infected tissues, the patient will be more comfort- 
able, and will live longer, if no radical operation is performed. The 
writer regards the presence of carcinomatous glands in the supraclavic- 
ular space in carcinoma of the breast, and extensive infiltration of the 
sacral glands in carcinoma of the uterus, as contraindications to a 
radical operation. The existence of a metastatic tumor or of diffuse 
miliary carcinosis is, of course, an absolute contraindication to an 
attempt to remove the primary tumor. The existence of a carcinoma 
in an unusual locality should induce the surgeon to make a critical ex- 
amination for the purpose of detecting the primary tumor, as when the 
mother-tumor can be located operative procedure is out of the question, 
as the metastatic origin of the tumor first discovered has then been 
demonstrated. If a carcinomatous patient is suffering at the same time 
from an otherwise fatal disease, such as pulmonary tuberculosis, Bright's 
disease, diabetes, cerebral softening, locomotor ataxia, etc., it is wisdom 
on the part of the surgeon to withhold the use of the knife and to limit 
his efforts to palliation. Unfortunately, it is seldom that the surgeon 
has the opportunity to give the patient his advice in time. In the great 
majority of cases he has to deal with carcinoma after regional infection 
has set in, and in cases in which the disease has advanced too far for a 
successful radical operation he must content himself with resort to 
palliative measures. 

Palliative Operations. — In inoperable subcutaneous carcinoma it 
should be the aim of the surgeon to preserve the cutaneous surface 
over the tumor intact so long as possible, as the misery which attends 



268 PATHOLOGY AND TREATMENT OF TUMORS. 

this condition is much less than in open carcinoma, and life is prolonged 
by the avoidance of septic infection. The surface of the tumor should 
be kept covered by aseptic absorbent cotton held in place by a circular 
bandage or by strips of adhesive plaster. If the skin becomes red and 
its perforation by the tumor-mass is threatened, the complication should 
be anticipated by a timely resort to antiseptic precautions, so that when 
an ulcer forms infection with pathogenic microbes will be prevented. 
The surface of the tumor should be disinfected in the same manner as 
in making preparations for an operation, after which it is covered by 
a few layers of iodoform gauze, over which is applied a thick compress 
of sterilized gauze, and the whole is covered by a filter of absorbent 
cotton. After the skin has given way the dressing is changed as often 
as necessary, and at each change the surface of the ulcer is washed 
with an antiseptic solution. Should the dry dressing prove a source 
of discomfort to the patient, it is replaced by a thick gauze compress 
wrung out of a saturated solution of acetate of aluminum and kept 
covered by an impermeable fabric like oiled silk, thin rubber sheeting, 
or mackintosh cloth. Attempts have been made, by covering large 
carcinomatous ulcers by skin-grafting, to render the condition of the 
patient more endurable by transforming the open ulcerating tumor into 
a subcutaneous lesion. These attempts have proved successful in some 
instances, but it is doubtful if the gain of such short duration will over- 
balance the pain and inconvenience caused by the scraping and the 
transplantation of Thiersch's skin-grafts. If the carcinomatous ulcer 
has become infected with pyogenic and putrefactive microbes, the sur- 
geon has to contend with an additional evil. It is an exceedingly diffi- 
cult task to render such a surface aseptic by chemical disinfectants. 
The surface is so irregular, and there are so many inaccessible nooks 
and corners which the solutions and powders cannot reach, that com- 
plete disinfection with chemical agents is usually not attained. The 
remedies which have proved most efficient in correcting the odor in 
such cases are Labarraque's solution of chlorinated soda, chlorine- 
water, aqueous solution of iodine and bromine, and iodoform in powder 
or mixed with boric acid (1:5). The strength of the solutions should 
not be such as to produce pain. If these milder measures do not 
succeed, a strong solution of chloride of zinc (25 per cent.) should be 
tried. 

Temporary benefit is always derived from a vigorous use of Volk- 
mann's sharp spoon. The necrosed tissue attached to the ulcerated 
surface is the soil in which the putrefactive bacilli live and multiply : 
their removal with the sharp spoon, including in the curettage also the 
fungous, bleeding masses, removes the culture-medium of the microbes 



CARCINOMA. 269 

which have caused the putrefaction, and will accomplish more than the 
use of chemical agents in rendering the ulcer aseptic. The scraping 
operation should be followed by the use of the actual cautery. The 
vigorous use of the flat point of the Pacquelin cautery will accomplish 
a great deal in this direction without the use of the sharp spoon. 
Scraping and cauterization have proved of great value in mitigating 
the distress in inoperable cases of carcinoma of the uterus, the breast, 
and the mouth. 

The removal of a carcinomatous breast as a palliative measure is 
occasionally indicated when enough skin can be preserved to cover 
the wound, and in this manner transform an open into a subcutaneous 
carcinoma. The ligation of the principal artery to a part the seat of 
carcinoma is indicated only when hemorrhage is threatened or has 
actually occurred and cannot be controlled by more conservative 
measures. In inoperable carcinoma of the uterus antiseptic vaginal 
injections should be employed at least once or twice a day. In carci- 
noma of the mouth an antiseptic gargle or spray is indicated. Trache- 
otomy in inoperable cases of carcinoma of the larynx, and colostomy 
in the same condition of the rectum, are exceedingly useful and grate- 
ful palliative operations. Gastrostomy in impermeable carcinomatous 
stricture of the oesophagus, gastro-enterostomy in pyloric carcinoma, 
and suprapubic cystotomy in advanced cases of carcinoma of the 
prostate gland, afford great relief and should always be suggested in 
appropriate cases. 

Radical Operations. — Operations which are intended to remove 
all the infected tissues, local and regional, are called " radical " opera- 
tions. A radical operation is indicated in all cases in which general 
infection has not occurred, and the primary and original tumors are of 
such size and extent and arc so located as to enable their complete removal 
by an operation not immediately endangering the life of the patient, and 
leaving a wound which can be closed by suturing or which can be healed 
by a plastic operation or by skin-grafting, and the patient's strength is 
such as to warrant the operation. 

If a radical operation is undertaken, it should be radical. The 
surgeon must not forget that carcinoma extends in the vicinity of the 
tumor along pre-existing connective-tissue spaces, and that conse- 
quently the zone of infiltration can be removed only by including with 
the primary tumor a wide strip of apparently healthy tissue on all sides. 
The incisions should be carried from four lines to an inch away from 
the macroscopical boundary-line of the tumor, according to the charac- 
ter of the tumor, its size, and its environment not only on one or two 
but on all sides. If the tumor is near the surface, the overlying skin 



270 PATHOLOGY AND TREATMENT OF TUMORS. 

should be removed. A zone of apparently healthy tissue at the base of 
the tumor as well as on the sides should be included in the excision. 
No blunt force should be used in the removal of the primary tumor ; 
its removal must be effected by a clean dissection. Pressure and tear- 
ing are liable to give rise to traumatic dissemination. Grasping the 
tumor with vulsellum forceps is attended by the same danger. If vul- 
sellum forceps are necessary to bring the tumor near the surface, the 
instrument should be so applied as not to penetrate the tumor. If the 
tumor is located in a part of the body from which the circulation can 
temporarily be excluded by elastic constriction, this should be made 
use of, as the bloodless procedure enables the surgeon to identify the 
tissues more accurately, and aspiration of tumor-cells or of fragments 
of tumor-tissue into the open lumen of cut veins is less likely to occur. 
If temporary hemostasis is inapplicable owing to the location of the 
tumor, the hemorrhage should be arrested as the operation pro- 
ceeds, for if this precaution is not practised projecting parts of the 
tumor may be overlooked and not again be found after the tumor has 
been removed. The external incision must be made at a point which 
affords easy access to the tumor, and in a direction parallel with important 
muscles, nerves, and vessels. The external incision must be large enough 
to expose freely the entire periphery of the tumor to sight as well as to 
touch, and if this cannot be done safely by one straight or curved incision, 
it is joined at sidtable points by cross cuts. The margins of the wound 
during the operation must be kept out of the way by retractors. The 
tumor and the surrounding zone of infiltrated suspicious tissue should be 
removed in one mass. The removal of projecting portions after the 
removal of the tumor is bad practice and should be avoided. 

The dissection must be made through healthy tissue outside the 
zone of infiltration from the beginning to the end of the operation. 
The employment of the dilute nitric-acid test, as suggested by Stiles, 
to ascertain during an operation whether or not all the diseased tissues 
have been removed, is not reliable and is of no use to the careful 
dissector. If the tumor after its removal is immersed in the 5 per 
cent, nitric-acid solution, the " boiled-egg" appearance upon some parts 
of the tumor will show that fragments of considerable size have been 
left behind, but it will fail in demonstrating that cellular remnants of 
the tumor have not been removed. In small carcinomata of the lip or 
of the skin presenting no evidences of glandular infection it is sufficient 
to excise with the tumor a zone of apparently healthy tissue in order 
to remove the peripheral invisible part of the tumor. In operating 
upon the lip it is not advisable to plan the details of a subsequent 
plastic operation, as there is great danger that the surgeon will be 



CARCINOMA. 271 

guided in the excision of the carcinoma by the plans of the restorative 
part of the operation. The prime indication of the operation should be 
to remove all the diseased tissues, regardless of the cosmetic result. After 
the carcinoma has been removed the surgeon sutures the wound in 
such a manner as to secure the best possible cosmetic results, or he 
resorts at once to a plastic operation. 

In the removal of all carcinomatous tumors the incision or in- 
cisions should be made in the direction of the lymphatics, because it is 
in this direction that the local infection becomes regional. In gland- 
ular carcinoma the entire gland should be removed if the gland so 
affected does not perform a function essential to the maintenance of 
health and life. Partial removal of the breast or the parotid or sub- 
maxillary gland for carcinoma cannot be condemned too strongly. 
If any doubt exists in regard to the presence of regional infection, 
the lymphatic glands through which regional infection would occur 
should be exposed by an incision, and if any of the glands are found 
enlarged, the entire chain of glands should be removed in one uninter- 
rupted piece with the primary tumor. In carcinoma of the breast the 
axillary region from the margin of the gland to the apex should be 
cleared of lymphatic glands and connective and adipose tissue, regardless 
of the condition of the glands. Typical cleaning out of the axillary 
space is urgently indicated in all cases of carcinoma of the breast. 
The whole chain of glands, with the surrounding connective and adi- 
pose tissue, must be removed by a clean dissection. The same plan 
should be pursued in the removal of the external genitals with infection 
of the inguinal gland. 

Enucleation of carcinomatous glands is invariably followed by recur- 
rence. Rupture of glands by pressure or traction is apt to be followed 
by traumatic dissemination. The primary tumor and regional tumors 
and healthy glands, with the tissues surrounding them, should be 
removed in one uninterrupted piece : this will ensure the removal of 
the connecting lymphatic channels which are so often the seat of 
regional infection. The wound after the removal of a carcinoma should 
be covered at once by integument : if this cannot be done by the use 
of sutures, the surface should be covered by a plastic operation or by 
skin-grafting. Healing of the entire wound by primary intention shoulc 
invariably be aimed at in the removal of a carcinoma by excision. 

The use of caustics in the radical treatment of carcinoma has a limitec 
field of usefulness. Caustics should be used only when patients object 
to the use of the knife, and their use should be restricted to small car- 
cinomata of the skin. Chloride of zinc should be given the preference 
over arsenic or the mineral acids. The treatment by caustics is more 



272 PATHOLOGY AND TREATMENT OF TUMORS. 

painful than excision under local or general anesthesia, requires more 
time, and the cosmetic result is less satisfactory. 

Topography. 

The study of the topographical distribution of carcinoma is an in- 
teresting one, as it tends to show that carcinoma is most frequently 
found in localities in which the most active and complicated tissue- 
changes take place in the embryo, and in situations most exposed to 
injuries, irritations, and other post-natal influences which result in 
diminution of the physiological resistance of the tissues. We also find 
it frequently in localities the favorite seat of benign epithelial tumors. 
The influence of age, sex, and occupation in determining the origin of 
carcinoma in certain parts and organs of the body has repeatedly been 
referred to. 

Skin. — Squamous-celled carcinoma occurs most frequently upon 
the lower lip, the eyelids, the labia, and the glans penis ; it is also fre- 




'WL 






,-,.« 



#?V- 






^,t:V"(' 



**%-:•■•--" "<. *" 

Fig. 150. — Carcinoma of skin of nates; V no, reduced one-third (Surgical Clinic, Rush Medical Col- 
lege, Chicago) : a, hypertrophied stratum corneum ; b, growth of epithelial cells into subcutaneous tissue; 
c, epithelial nest in vascular connective tissue 

quent in the mouth, the oesophagus, the vagina, and about the cervix 
uteri. When the growth takes its starting-point in the sudoriparous 
or sebaceous glands, the cells of the carcinoma are cuboidal in shape 



CARCINOMA. 



273 



and the growth presents a tubular structure. The latter variety is most 
frequent on the nose and the eyelids, and is least malignant. 

Histological Structure. — The manner of growth and the forms of epi- 
thelial tissue are varied, and the changes to which a carcinoma is subject 
are manifold. The stroma supplies the vascular part of the papillary 
excrescences, yields to the penetrating epithelial cells, surrounds the 
epithelial nests with a network of vessels, and finally becomes the seat 




Fig. 151. — Vertical section througn carcinoma of the skin ; X 50 (Surgical Clinic, Rush Medical College, 
Chicago) : a, subcutaneous connective tissue and stroma of tumor; b, proliferation of epithelial cells into the 
connective tissue ; c, sebaceous gland in a state of active tissue-proliferation ; d, normal tissue not yet affected 
by the carcinoma 



of ulcerative destruction. The equilibrium between the hyperplastic 
masses of epithelial cells and the underlying vascular connective tissue 
is destroyed with the beginning carcinomatous process. Conditions 
apparently leading to embryonal development of papillary and follicular 
structures appear to be arrested, and a functionally useless, planless 
growth supervenes. Generally the preponderant growth of epithelium 
initiates the change ; this, however, is to be found not so much on the 
part of the proliferating epithelial cells as in a lessened resistance of the 
adjacent tissues. The first evidence of the appearance of epithelial 
is 



274 



PATHOLOGY AND TREATMENT OF TUMORS. 



cells in the vascular connective tissue underlying the epithelial layer 
of the skin announces the transition of the benign into the malignant 
stage of carcinoma (Fig. 150). Vertical section through a carcinoma 
of the skin in its earliest stages shows thickening of the layer of 
epithelial cells between the epidermis and the membrana propria 
(Fig. 150, b). As soon as the epithelial cells have reached the con- 
nective tissue they form nests. The glands of the skin in the area 
of carcinomatous infiltration assume more active tissue-proliferation, 
which results in increased secretion (Fig. 151). The stroma in the non- 




Fig. 152. — Carcinoma of the skin, showing alveolated structure of the stroma and numerous epithelial 
nests ; X 150 (Surgical Clinic, Rush Medical College, Chicago) : a, stroma ; b, epithelial infiltration of con- 
nective tissue; c, c, epithelial nests. 

ulcerating part of the tumor increases in quantity by proliferation of 
the pre-existing cells caused by the presence of the numerous epithelial 
cells, which to them are foreign bodies. The alveoli of the stroma are 
packed with epithelial cells (Fig. 152). The progressive infiltration of 
the skin from the surface is well shown in Figure 153. 

Thiersch has repeatedly traced the origin of carcinoma of the skin 
to sudoriparous glands. Carcinomata of such an origin present under 
the microscope a tubular structure resembling cylindrical-celled carci- 
noma of the mucous membrane (Fig. 1 54). 



CARCINOMA. 



275 










Fig. 153. — Vertical section through carcinoma of the skin, showing hair-follicle and epithelial nests; 
X 3°° (Surgical Clinic, Rush Medical College, Chicago) : a, hair-follicle containing a hair ; b, epithelial infil- 
tration ; c, stroma; d, large epithelial nest ; e, e, beginning formation of epithelial nests. 




* 



■/ --- ■ if . 

v» ■ .- ■<■■■■' 




Fig. 154. — Carcinoma of the skin starting from epithelial cells of sweat-glands ; X i3 (after Thiersch) : 
a, epidermis ; /', cutis ; c, normal lanugo-hairs with their sebaceous glands ; d, convoluted sweat-gland with 
distinct lumen ; e, branched and anastomosing proliferation of gland ; lumen can be seen only in part ; /, 
branched proliferation with terminal and lateral knob-shaped cellular projections ; g } round masses of cells, 
separate or in several groups, which lie loose in spaces of the connective tissue, and which appear either as 
terminal knobs or as transverse sections of cellular strings. 



276 PATHOLOGY AND TREATMENT OF TUMORS. 

In superficial ulceration of a carcinoma of the skin the papillary 
structure of the skin remains, and the surface presents the appearance 
of an ordinary ulcer (Fig. 155). As soon as a surface carcinoma be- 
comes the seat of microbic infection the connective-tissue stroma takes 
an active part in the suppurative process, as elsewhere. Destruction 
of the stroma by suppuration liberates the contents of the more super- 
ficial cell-nests, the contents being discharged with the inflammatory 
product. The progressive destruction of the stroma results in the 



} ""a - «, * ? *- 









<*Q* : i 







'*-*-■ 



Fig. 155. — Deep carcinoma of the skin of the heel : vertical section ; X *6 (after Thiersch) : a, papilla? 
of surface of ulcer; b, their epidermal covering ; r, vascular stroma ; d, inner surface of a parenchymatous 
cavity studded with papilla; ; e, epidermal covering of papilla; ; /, masses of cells in concentric layers in the 
interpapillary spaces ; £-, the same, belonging to the free epithelial masses. 

increase in size and depth of the carcinomatous ulcer. In ulcus rodens, 
only one of the many varieties of carcinoma of the skin, the stroma is 
very scanty ; hence progressive increase in the size of the ulcer and 
slight induration of its base and margins are conspicuous pathological 
features. 

Regional Infection. — Regional infection, usually a late occurrence in 
carcinoma of the skin, does not depend upon the size of the tumor or 
ulcer. The writer has seen glandular infection in connection with a 
carcinoma of the lip not larger than a pea, and has seen it absent in 



CARCINOMA. 2 

cases in which almost the entire lower lip was destroyed by the car: 
noma. The occurrence of glandular infection appears to be influenc 
more by the diminished loss of resistance of the connective tissue th. 
by the proliferation of epithelial cells. Of all the surface carcinoma 
affecting the skin, carcinoma of the lip is followed more constant 
by regional infection than carcinoma of any other part of the boc 
The submental glands are usually first involved, later the submaxillai 
and finally the cervical glands. The writer has seen the most mali 
nant form of regional infection develop several years after the remo\ 
of a small carcinoma of the lip by caustics or by the knife. 

For some reasons which remain unexplained, the upper lip is ve 
seldom the seat of carcinoma, and in the few cases which have cor 
under the observation of the writer there was no glandular infectic 
It has already been explained that the late glandular infection in can 
noma of the skin is attributable to the location of the tumor, and n 
to its lesser degree of malignancy than glandular carcinoma. A can 
noma surrounded on all sides by tissues has an extensive area of inf 
tration, while in surface carcinoma infiltration is limited to one directic 
In the former instance the tumor is subjected to pressure which mu 
favor lymphatic infection, while in surface carcinoma this cause of di 
semination of the tumor-elements is entirely wanting. The probab 
existence of regional infection must not be lost sight of in the operati' 
treatment of surface carcinoma. 

Degeneration of Tumor-tissue. — Fatty degeneration of the conten 
of the alveoli is the most frequent form of degeneration of carcinon 
of the skin. In the older parts of the tumor the alveoli contain on 
the product of this form of degeneration, all the epithelial cells havir 
undergone this change. In chronic cases calcification often follo\ 
fatty degeneration. Colloid and myxomatous degeneration, such co 
stant regressive metamorphoses in glandular and cylindrical-celled ca 
cinoma, occur less frequently, and never reach the same degree. Ear 
ulceration is the most characteristic feature of carcinoma of the ski 
The ulcer forms over the centre of the tumor, and spreads more < 
less rapidly in the direction of the base of the tumor and toward i 
periphery. As soon as the tumor-tissue is exposed the connectr 
tissue takes an active part in the ulcerative process. If the resistant 
of the connective tissue is not much reduced, granulations spring i 
from the stroma, the base of the tumor as well as the margins of tl 
ulcer become infiltrated with inflammatory product, and for a time 
may seem that the inflammatory process has exerted an inhibitoi 
influence on the local extension of the tumor. The inflammatoi 
material, however, serves only a temporary purpose in retarding tl 



278 PATHOLOGY AND TREATMENT OF TUMORS. 

extension of the tumor : the connective tissue and the exudation suc- 
cumb to the combined effects of tumor-growth and microbic infection, 
and the disease resumes its progressive tendencies. 

Lip. — Clinical Course. — Carcinoma of the lip usually commences at 
the junction of the mucous membrane with the skin. It seldom starts 
from the angles of the mouth and the upper lip. In a case of carcinoma 
of the upper lip that recently came under the observation of the writer 
the tumor appeared some distance from the margin of the upper lip 
(PI. 5, Fig. 2). The patient was a man forty-five years of age. The 
tumor was noticed five years ago, when it. was not larger than a millet- 
seed and appeared to be imbedded in the skin ; a year later the tumor 
commenced to increase in size, an ulcer formed on its surface, and the 
base became very much indurated. The base of the tumor was of the 
density of cartilage ; its surface was covered by fungous granulations. 
The margins of the ulcer were covered by overlying undermined skin. 

Carcinoma of the lower lip is common in men, but very rare in 
women. Konig estimates that the proportion of males to females is 
20: 1. Lortet's statistics show the proportion to be 7.6: 1. Warren 
observed 4 cases in women out of 73 cases, and states that 3 of the 
women were smokers. In 145 patients suffering from carcinoma Koch 
(Erlangen) attributed the affection in 15 to an injury. The tumor- 
formation is frequently preceded by a crack or a fissure or an eczema- 
tous condition of the margin of the lip. At a very early stage the 
centre of the indurated area ulcerates, and from the ulcerated surface 
the atheromatous contents of the exposed epithelial nests can be 
squeezed out. By extension of the ulcer the lower lip is destroyed 
(PL 5, Fig. 1), when the cheek, the chin, the lower maxilla, and the 
floor of the mouth are successively involved. The submental and sub- 
maxillary glands, which now have become enlarged, are often firmly 
attached to the lower jaw, simulating primary malignant disease of the 
periosteum or the bone. With few exceptions the disease, if allowed 
to pursue its course, terminates fatally within from three to five years. 
Death results from marasmus, from sepsis, or from general dissemina- 
tion of the disease. 

Diagnosis. — The superficial diffuse form of carcinoma of the lip is 
frequently mistaken for eczema. The deeper layers of the skin are 
exposed, presenting a papillomatous appearance. The raw surface is 
constantly moistened by a serous transudation. Careful palpation will, 
however, detect in the skin and the mucous membrane an induration 
which is absent in eczema of the lip. Chancre of the lip develops 
rapidly and is attended at an early stage by diffuse glandular infection. 
Secondary syphilitic lesions of the lip start usually in the mucous 



CARCINOMA. 



Plate 5. 





1. Carcinoma of the lower ]ip. 2. Carcinoma of the upper li] 



CARCINOMA. 279 

membrane of the mouth, and reach the lip by extension. Papilloma 
of the hp appears as a permanent tumor, and its base lacks induration. 
Primary tuberculosis of the lip is an exceedingly rare affection ; it 
occurs almost from the beginning as a more diffuse affection than 
carcinoma, and it lacks the induration so characteristic of carcinoma. 
Carcinoma of the lip appears as an ulcerating tumor zvitli indurated base 
and margins, which tumor ultimately gives rise to regional and o-cncral 
infection. If any doubt remains as to the nature of the tumor, a frao-- 
ment of tissue should be taken from the base or margin of the ulcer, 
from which sections should be made for microscopic examination. 

Pace. — Carcinoma of the skin in other localities usually pursues 
a course similar to that of carcinoma of the lip. The face is the 
most frequent seat of carcinoma of the skin. O. Weber found in 
740 cases of tumors of all kinds subjected to operative treatment 
133 cases of carcinoma of the face. The ages of the patients vary 
from forty to eighty. According to Thiersch, carcinoma of the skin 
appears either as a superficial ulceration (ulcus rodens) or it penetrates 
the tissues deeply and involves the different structures successively. 
If the carcinoma starts from the appendages of the skin, the colum- 
nar epithelial cells are arranged in groups resembling tubules ; if it is 
composed of squamous cells, it appears from the beginning as an in- 
filtration with small epithelial cells, which before ulceration occurs 
fill the alveoli of the stroma. Like carcinoma of the lip, carcinoma 
of the skin begins as a minute surface defect with a limited area 
of induration at its base. From this point the ulceration spreads un- 
equally in different directions, so that the ulcerated surface presents 
irregular outlines. In the superficial form of carcinoma peripheral 
extension takes place rapidly, but the destructive process is limited to the 
skin. In the penetrating or deep variety the ulceration extends at the 
same time in the direction of the base of the ulcer, involving succes- 
sively different tissues irrespective of their anatomical character. In this 
variety the ulceration is generally preceded by a deep infiltration of the 
skin and the subcutaneous connective tissue. So long as the papilla; 
of the skin remain, the surface of the ulcer presents a papillary appear- 
ance. When the papillae are destroyed, the epithelial nests are exposed, 
their contents escape with the inflammatory product, and the surface 
of the ulcer assumes a honeycomb appearance. The prognosis of this 
variety of carcinoma of the skin is more unfavorable than that of the 
superficial variety. The ulceration spreads very rapidly, and results in 
very extensive destruction of tissue in a remarkably short time. Lym- 
phatic infection occurs frequently at quite an early stage, and occa- 
sionally death results from metastatic tumors. Carcinoma of the face 



280 PATHOLOGY AND TREATMENT OF TUMORS. 

attacks most frequently the eyelids, the nose, and the malar and frontal 
regions. Carcinoma of the eyelids, if not removed in time, extends to 
the eyeball and the other contents of the orbit, causing not only loss 
of the eye, but also producing a frightful disfigurement. 

Diagnosis. — Carcinoma of the face must be distinguished from tu- 
berculosis, syphilis, suppurating benign growths, and retention-cysts. 
Tuberculosis of the face, the so-called " lupus," often appears as a 
multiple affection. The same can be said of tertiary syphilitic lesions. 
Multiple carcinomatous tumors are exceptional, and they almost always 
originate from the transformation of senile warts into carcinomata. 
Tubercular ulcers often heal, in part or completely, spontaneously or 
under appropriate local treatment — something never observed in carci- 
noma. The base of the tubercular ulcer presents to the palpating 
finger a doughy, cedematous sensation ; the base and margins of the 
carcinomatous ulcer are firm and indurated. Careful examination of 
patients suffering from tertiary syphilitic affections of the skin usually 
reveals additional syphilitic lesions in other parts of the body, or traces 
of former affections that have healed. If any doubt remains, the 
patient should be given the benefit of the doubt by subjecting him to 
antisyphilitic treatment for a number of weeks. The differential diag- 
nosis between carcinoma and tubercular affections of the skin may 
require the use of the microscope and a resort to inoculation experi- 
ments. The former will reveal the typical structure of the existing 
affection, and the latter will yield positive results if the lesion is tuber- 
cular, and negative if it is a carcinoma. 

Operative Treatment of Carcinoma of the Lip. — The best curative 
and cosmetic results are obtained by early and thorough excision. 
If the tumor is small, the operation can be done without anesthesia ; 
if large and if a plastic operation must follow to correct the defect, 
partial anesthesia will answer the purpose. The coronary artery should 

be compressed at both angles of the mouth 
by compression-forceps or between the 
thumbs and index fingers of the hands of 
an assistant. In diffuse superficial carci- 
noma of the lip involving only the mucous 
and submucous tissues the entire margin 
of the lip, from one angle of the mouth 
to the other, is excised. The incision is 
Fig. 156.— Suturing after excision of made at a safe distance (about half an inch) 

the entire margin of the lip for carci- r .1 1 i 1 r 1 

noma (after Esmarch) from the palpable margin of the tumor; 

the mucous membrane is then carefully 
stitched to the margin of the skin with fine catgut sutures (Fig. 156). 








CARCINOMA. 



28l 



The cosmetic and functional results following this operation are entirely 
satisfactory. The lip is long enough to retain the secretions of the 
mouth, and there is formed from the mucous membrane a new pro- 
labium which in the course of a few months resembles the normal 
prolabium in appearance. 

If the tumor involves not quite one-half of the lip and has pene- 
trated the tissues deeply, it is included in a V-shaped incision the apex 
of which must extend to the lower border of the jaw (Fig. 157). The 





Fig. 157. — Wedge-shaped excision of the lip for car- 
cinoma (after F.smarch). 



Fig. 158 —Operation completed (after Esmarch}. 



coronary artery is either twisted or included in one of the deep sutures. 
The deep sutures of silk or of silkworm gut should embrace all the 
tissues except the mucous membrane, which should be sutured with 
fine catgut from the mouth before the deep sutures are tied, in order to 
prevent the interposition of mucous membrane between the margins of 
the wound. The lower lip gradually elongates after the operation 
(Fig. 158). 

If the tumor involves more than one-half of the lip, it should be 
excised by a curved incision, with the convexity directed downward, at 
least half an inch distant from the palpable margin of the tumor. The 
mucous membrane is then sutured over the surface of the wound to 
the skin. The semilunar defect, which is quite apparent after the 
operation, gradually diminishes in the course of time. If the whole 
or nearly the whole lip is involved, complete excision becomes neces- 
sary, and a new lip must be made by a plastic operation. Wolfler 
recently described an operation which yielded excellent results : After 
excision of the entire lip a curved incision about two inches below 
the margins of the wound, and extending a little beyond the angles 
of the mouth, is made through the skin and the subcutaneous con- 
nective tissue. The quadrangular flap is then so raised that its upper 
margin will occupy the normal level of the lip, when the flap is sutured 
to the anterior surface of the jaw with catgut sutures, so as to ex- 
clude from the wound the cavity of the mouth and to fix the new lip 
securely in its new place. The flap is retained by a proper dressing 



282 PATHOLOGY AND TREATMENT OF TUMORS. 

in this position. After clearing out the submental and submaxillary 
spaces of lymphatics, the lower margin of the wound is sutured sepa- 
rately to the jaw and the new lip, and drainage is established through 
a small buttonhole in the centre at the most dependent part of the 
wound. If the whole wound cannot be covered with skin in this man- 
ner, the remaining surface should be paved with Thiersch's skin-grafts. 
As soon as the flap is detached the submental and some of the sub- 
maxillary glands come in view, and should be dissected out carefully 
with the adjacent connective and adipose tissue. Langenbeck restored 
the lower lip by taking a flap from the region of the neck (Figs. 159, 
160). In this operation it is necessary! after the formation of the flap, to 
carry the incision downward in the median line to expose and remove 
infected lymphatic glands. 

The great difficulty in Langenbeck's operation is that the free mar- 
gin of the new lip cannot be covered with mucous membrane, and a 
certain amount of cicatricial contraction ensues durinsr the healine of 
the wound. In Wolfler's operation there can often be preserved a 





Fig. 159. — Langenbeck's method of restoring the Fig. 160. — Operation completed (after Langen- 

lower tip after excision for carcinoma (after Lan- beck), 

genbeck). 

narrow strip of mucous membrane with which to line the free margin 
of the lip and thus to secure in the course of time a normal prolabium. 
Partial excision of the upper lip is made in the same way as for car- 
cinoma of the lower lip. If the entire upper lip has to be excised, the 
defect is restored after the method devised by Bruns (Figs. 161, 162). 
The two lateral flaps are brought down to the proper level, are united 
in the median line by a number of sutures, and are stitched to the 
margin of the wound below the nose ; finally, the wound on each side 
is diminished in size as far as possible by suturing. In plastic opera- 
tions a number of superficial sutures of horsehair are always of great 
service to bring the skin in accurate coaptation. The sutures should 



CARCINOMA. 283 

be removed as soon as the union is firm enough to render them super- 
fluous, which will be the case in from three to five days. 

Sutures should be tied carefully, and only with firmness sufficient 
to bring the margins of the wound in contact. Tension from tying the 





Fig. 161.— Cheiloplasty (after Brans). Fig. 162.— Operation completed (after Brans). 

sutures too tightly not only gives rise to pain, but also interferes with 
an ideal healing of the wound. A suture that causes undue linear 
compression should be removed at once. If the flap in plastic opera- 
tion does not require an external mechanical support, the writer is not 
in the habit of applying a dressing in operations upon the lip. The 
operation should be performed under strict antiseptic precautions, and 
after its completion the line of suturing should be covered by a thin 
layer of carbolated vaselin. 

Operative Treatment of Carcinoma of the Face. — The eyelids are 
quite frequently the seat of carcinoma. An early operation in this 
locality is of the utmost importance, as the disease always manifests 





Fig. 163. — Blepharoplasty after removal of carci- 
noma of lower eyelid (after Dieffenbach). 



Fig. 164.— Operation completed (after Dieffen- 
bach). 



a tendency to extend to the eye and the other contents of the orbit. 
If the operation is performed before the conjunctiva has become 
involved, the functional and cosmetic results are satisfactory. The 
incisions circumscribing the tumor should be made at a safe distance, 
and the conjunctiva should be preserved carefully. The defect is 
remedied in a satisfactory manner by Dieffenbach's method (Figs. 163, 
164). The tumor is included in a V-shaped incision, and the part to 



284 



PATHOLOGY AND TREATMENT OF TUMORS. 



be removed is carefully dissected away from the conjunctiva. If the 
tumor has reached the tarsal cartilage, this must be removed with the 
eyelashes. A square flap is now made by carrying a straight incision 
from the outer angle of the eye outward and backward, corresponding 
in length to the length of the eyelid, joined at the outer terminus by 
an incision extending downward and inward to a level with the apex 
of the V-shaped incision. The flap is now detached and by sliding is 
brought into its new location, when the operation is completed by 
suturing with fine silk, catgut, or horsehair, as shown in Figure 164. 
The wound-surface which cannot be covered by suturing should be 
paved by Thiersch's grafts at once. 

If the disease has extended to the conjunctiva, the entire eyelid must 
be removed. In such cases it is much more difficult to replace the parts 
lost by disease than those lost by the operation. Dieffenbach's method 
must be modified so far that the inner surface of the new eyelid should 
be covered with a Thiersch graft, which should be retained in its proper 
position by a few fine catgut sutures. Hotz has shown that conjunc- 
tival defects can be repaired successfully by skin-grafts. The writer has 
resorted to this expedient a few times in making new eyelids, and the 
results have been exceedingly satisfactory. The skin grafted soon 
adapts itself to its new location and serves a useful purpose as a sub- 






Fig. 165. — Partial rhinoplasty by taking a 
flap from the opposite side of the nose (after 
Langenbeck). 



Fig. 166. — Partial rhi- 
noplasty completed (after 
Langenbeck). 



Fig. 167. — Partial rhinoplasty 
by taking a pedunculated flap 
from the face along the base of 
the nose (after Esmarch). 



stitute for the conjunctiva. A new eyelid lined on both sides by skin 
is less liable to shrink and to become distorted than when skin-graft- 
ing is omitted. 

Operative Treatment of Carcinoma of the Nose. — If only a part of 
one ala of the nose is affected, the carcinoma is excised by removing 
a wedge-shaped piece the entire thickness of the ala, and the defect is 
corrected by taking a flap from the opposite side of the nose, as advised 
by Langenbeck, or from the face near the base of the nose (Figs. 165, 



CARCINOMA. 



285 



166). The wound left on the opposite side of the nose after the 
removal of the flap should be covered by a pavement of Thiersch 
skin-grafts. The nasal defect after the excision of the carcinoma can 
also be remedied satisfactorily by taking a pedunculated flap from the 
face, as shown in Figure 167. If the margins of the nasal apertures 
are free, and the tumor occupies the bridge of the nose and has in- 
volved the bony framework, a very extensive operation becomes neces- 
sary. With knife, chisel, and saw, the tumor and the bony framework 
are removed to ensure complete removal of all diseased tissue. If the 
disease has reached the nasal cavities, extensive removal of the mucous 
lining of the nasal passages often becomes necessary. The resulting 
defect often presents alarming proportions, but it can be corrected in 
a very satisfactory manner by Konig's operation (Figs. 168, a, b, c). 





Fig. 168. — Konig's rhinoplasty. A: a, flap for building bridge of nose, including skin, periosteum, 
and a thin slice of bone ; b, flap used to cover flap a and to furnish integument for the entire defect ; c, defect 
caused by excision of tumor. B : a. flap a turned downward; b, lower end fastened in place with catgut 
sutures. The skin of the tip of the nose at b is left free, and to it flap b is sutured, c : a, b, defects over 
frontal bone ; c y flap b, which covers the bony surface of flap a, and furnishes the cutaneous covering for the 
entire defect, sutured in place. 



The reflected flap a furnishes a bridge of bone which prevents the sink- 
ino- in of the nose. The defect over the frontal region caused by the 
removal of the flaps should be covered at once by large skin-grafts. 
If the entire nose has to be sacrificed, owing to the extent of the carci- 
noma, Thiersch's method of rhinoplasty recommends itself for restoring 
the lost organ. The new organ is made by taking a flap from each 
side of the face; these flaps are turned inward with the cutaneous sur- 
face downward, and are then united in the middle line with catgut 
sutures. A large pedunculated flap is then taken from the forehead 



286 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fit;. 169. — Rhinoplasty (after Thiersch). 



and is rotated into position and sutured in place. The two raw sur- 
faces brought in contact unite rapidly, and as both sides of the alae of 
the nose are lined by normal skin, the resulting shrinkage is moderate. 

The defects caused by the removal of the 
flaps are covered at once by Thiersch 
grafts. 

Carcinoma of the skin in other parts 
of the face or the body is excised with the 
same thoroughness, making the incisions 
half or three-quarters of an inch away 
from the palpable margins of the tumor, 
and covering the defect either by a plastic 
operation, by skin-grafting, or by a com- 
bination of both these procedures. In per- 
forming primary skin-grafting it is very im- 
portant to diminish the size of the wound 
by suturing its angles and by approximating the remaining margins of 
the wound by the use of tension-sutures. The best material for this 
purpose is coarse silk. The skin-grafts should be covered carefully by 
strips of protective silk over which an antiseptic dressing is applied, the 
whole being held in place by strips of adhesive plaster or by a plaster- 
of-Paris bandage, so that the grafts may not subsequently be disturbed. 
Unless positive indications arise, the first dressing should not be dis- 
turbed for three days. In place of Thiersch's grafts, it may be advis- 
able under certain circumstances to use Wolfe's grafts. Grafts not 
deprived of all adipose tissue should not be used, as this method of 
skin-grafting, contrary to the assertions of Hirschberg, often results in 
failure. 

Mouth. — Carcinoma of the mouth has the same structure as carci- 
noma of the skin, as the glands and the mucous membrane of this 
cavity have an embryonic origin similar to that of the skin. Before 
the fourth week in the life of the human embryo there is developed 
at the lower part of the face a broad transverse cleft : this is the primi- 
tive mouth. Developed as it is from the face, and carrying with it 
the covering of the face, the lining membrane of the mouth is derived 
from the epiblast. The buccal part of the epiblast forms a sac that is 
at first closed posteriorly. Not until the eighth or the ninth week 
is a communication established between the mouth and the pharynx. 
The mouth and the pharynx in the embryo are two separate cavities, 
the first having its origin in the epiblastic layer, the second in the 
hypoblastic layer and the visceral mesoblast. The glands in communi- 
cation with the mouth are developed from the epiblastic lining of the 



CARCINOMA. 2i 

mouth. The mouth is covered by pavement epithelium several laye 
deep, the deeper or attached layer being generally columnar, while tl 
superficial layer presents flattened scales. In the mouth, as in the ski 
carcinoma starts either in the epithelial strata of the mucous membrar 
or in one of its glandular appendages, in the form of a hard nodul 
The epithelial cells undergo fatty degeneration, so that when an ulo 
has formed an atheromatous mass can sometimes be pressed from tl 
centre of the ulcer. The base of the ulcer is indurated. The ulce 
instead of showing any disposition to cicatrize, enlarges in all direction 

The superficial variety, as in the skin, manifests no disposition 1 
invade the deep structures. The nodular variety originates in tl 
tubular mucous glands, and presents under the microscope a tubul; 
structure. The tubules are lined with one or more layers of column; 
epithelial cells. This form from the very beginning penetrates tl 
tissues deeply after invading one of the maxillary bones at an ear 
stage. As a primary tumor, carcinoma of the mouth is rarely deve 
oped in localities other than the lips, the gums, the salivary glands, tl 
tongue, the tonsil, and the palate. The labial glands are much mo 
numerous in the lower than in the upper lip, and they are almost entire 
absent about the angles of the mouth ; which absence may tend i 
explain why carcinoma affects the middle of the lower lip more fr 
quently than the upper lip and the angles of the mouth. Carcinon 
of the mouth is frequently attributed to smoking, but in the East, whe 
this habit is most common and is carried to excess, carcinoma of tl 
lip and the mouth is very rare. This fact would seem to prove, if smol 
ing is an etiological factor, that it is not the traumatism resulting fro 
the pipe, but the heat, that is the active agent, as long pipe-stems a 
used by the Orientals and the smoke is passed through water before 
reaches the mouth. 

Carcinoma of the mucous membrane of the cheek is sometim- 
preceded by a patch of leukoplakia. The influence of chronic irrit 
tion in producing carcinoma is well shown in carcinoma in this localit 
as the tumor very often corresponds in its location with the crowns c 
prominent upper and lower molar teeth. 

Carcinoma of the gum starts often near the stump of a carious toot 
The bone is invaded so quickly that the disease is often mistaken for 
primary bone affection. Lymphatic infection is a very early and co; 
spicuous feature when the carcinoma involves either of the maxillai 
bones. The primary tumor is sometimes overlooked in such cases. . 
rapid-growing glandular tumor of the neck should remind the su 
geon of the necessity of a thorough examination of the cavity of tl 
mouth. Carcinoma of the mouth with early and extensive glandul; 



288 PATHOLOGY AND TREATMENT OF TUMORS. 

infection is a very rapidly fatal affection, the average duration of life 
being not more than six months. 

Radical operations for carcinoma of the mouth always require an 
external incision. Intra-oral operations cannot be made with the requi- 
site degree of thoroughness. The incision must be made in a location 
which affords the best access to the tumor, and in which the operation 
will leave the least disfigurement. If the upper maxilla is implicated, 
the same incisions are made as for partial or complete excision of this 
bone. If the lower jaw has become secondarily affected, the floor of the 
mouth is usually also extensively involved. In such cases a horseshoe- 
shaped incision corresponding with the lower border of the jaw from 
one angle to the other will afford ample space to remove a portion of 
the bone and to clear out the infected glands and other soft tissues 
requiring removal. In cases of extensive carcinoma of the mouth recur- 
rence is very apt to take place even after the most extensive operations, 
owing to the early and extensive lymphatic infection. 

Tonsil. — Carcinoma of the tonsil is a comparatively rare affection. 
Only two or three cases have come under observation in which the 
writer could satisfy himself that the disease had its primary origin in 
this gland. In one of the cases the tumor was mistaken for a long 
time for primary syphilis, and the patient had been subjected to anti- 
syphilitic treatment for several weeks, with, of course, a negative result. 
The infiltration spreads very rapidly, and early lymphatic infection is 
the rule. The disease in the course of two or three months extends to 
the base of the tongue, the pillars of the soft palate, and the pharynx. 
Salivation, pain, and dysphagia are early and distressing symptoms. 
As soon as the disease reaches the entrance of the larynx, hoarseness 
and difficult breathing set in. As the disease occurs only in persons 
advanced in years, the diagnosis is not attended by any difficulty. The 
malignancy of the tumor is pronounced by the clinical course, and all 
that remains for the surgeon to do is to differentiate between carcinoma 
and sarcoma. In carcinoma ulceration commences at an earlier stage 
than in sarcoma, and is more constantly attended by infection of the 
lymphatic glands, which infection is exceptional in sarcoma. 

Operative Treatment of Carcinoma of the Tonsil. — The removal of a 
malignant tumor of the tonsil is one of the most difficult operations in 
surgery. At the time the operation is performed the disease has usually 
extended far beyond the limits of the organ primarily affected. The 
tumor must be exposed by an external incision, with or without tem- 
porary resection of the inferior maxilla. O. Weber recommended 
temporary resection of the inferior maxilla at a point corresponding 
with the third molar. The articular end of the bone is then turned 



CARCINOMA. 



289 




upward with the soft tissues. The ascending pharyngeal, lingual, facial, 
and carotid arteries can readily be tied in this incision. Mikulicz advises 
an external incision extending from the mastoid process to the hyoid 
bone, after which the ascending ramus of the jaw is denuded of its 
periosteum from the insertion of the masseter muscle as high up as 
possible, whereupon the ascending ramus of the jaw is enucleated. 
The tonsillar region is now freely exposed. Langenbeck recommends 
temporary resection of the inferior maxilla 
(Fig. 170). Cheever of Boston, who recom- 
mends an incision along the anterior border 
of the sterno-cleido-mastoid muscle from the 
external ear in a downward direction, reports 
several cases operated upon successfully by 
this method. In two cases in which this ope- 
ration was performed by the writer he resorted 
to Kocher's incision for the removal of the 
tongue, and, although both operations proved 
exceedingly difficult, he was satisfied with the 
room afforded by the incision. 

Iodoform-gauze drainage should be em- 
ployed both for the purpose of arresting 
parenchymatous oozing and to afford a free 
outlet for the primary wound-secretions. If 
temporary resection of the inferior maxilla is practised, the intentional 
fracture is sutured with silver wire or with chromicized catgut after the 
extirpation of the tumor. 

Tongue. — Carcinoma of the tongue is one of the most distressing 
of all surgical affections. Unfortunately, the tongue is rather frequently 
the seat of carcinoma. The 
lingual glands are distributed 
at the root of the tongue, on 
the sides, and at the apex, and 
it is in these localities that the 
tumor has most frequently its 
starting-point. Very frequently 
the location of the tumor cor- 
responds with a source of irri- 
tation caused by a prominent 
or carious tooth. Mechanical 
irritation from such a source 
continued for any length of 
time is very apt to become an influential exciting cause 

19 



Fig. 170, — External incisions 
for extirpation of carcinoma of the 
tonsil : a, after Langenbeck ; b, 
after Mikulicz. 




Fig. 171. — Carcinoma of the tongue, showing its papillary 
structure; X 100 (after W. Fairlie Clarke). 



Th 



e propor- 



290 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 172. — Carcinoma of the tongue : laminated cap 
sule ; X 20° (after \V. Fairlie Clarke). 



tion of female to male patients is about 1:7. In the early stages, 
before ulceration has become extensive, the tumor retains on its sur- 
face the papillary structure of the tongue (Fig. 171). Infiltration from 
the surface soon results in the formation of epithelial nests in the 
underlying vascular connective tissue. The epithelial cells are closely 

packed in concentric layers in the 



alveoli of the stroma (Fig. 172). 

Besides chronic irritation, the 
most frequent exciting causes of 
carcinoma of the tongue are psori- 
asis, leukoplakia, ichthyosis, and 
other chronic inflammatory affec- 
tions of the surface of the tongue 
— a strong argument that chronic 
inflammatory affections are a fre- 
quent direct and indirect cause of 
carcinoma. Usually carcinoma of 
the tongue is a rapidly fatal dis- 
ease, resulting in death within two years. Wolfler has called attention 
to a more chronic form of carcinoma of the tongue in which a small 
flat carcinomatous ulcer may remain in a latent condition for many 
years. The tumor makes its appearance at the margin, tip, or dorsum 
of the tongue, as a firm nodule which soon begins to ulcerate in 
the centre. The infiltration and induration are well marked from the 
beginning. The primary tumor seldom or never occupies the posterior 
third of the organ. Glandular infiltration is an early sequence, and the 
floor of the mouth becomes involved at an early stage. 

The pain in carcinoma of the tongue is quite severe and of a sharp, 
stinging character, extending also in the direction of the ear. The 
surface of the ulcer is either papillary or covered by gangrenous shreds. 
The induration of the base and margins of the ulcer remains through- 
out. Profuse salivation and difficulty in swallowing and in speech are 
conspicuous clinical features. 

In the differential diagnosis tuberculosis, gumma, traumatic ulcer, 
and actinomycosis must be considered. Tuberculosis of the tongue 
occurs, with few exceptions, only in persons suffering from pulmonary 
tuberculosis. The tubercular sputum, coming in contact with some 
abrasion, results in inoculation. The tubercular ulcer is covered by 
fungous granulations, and lacks the indurated base and margins of car- 
cinoma. Syphilitic lesions have frequently been mistaken for carci- 
noma, and vice versa. Gumma of the tongue is usually associated with 
other syphilitic manifestations of the tongue or of the cavity of the mouth. 



CARCINOMA. 



291 



The tongue itself is often deeply fissured. General hyperplasia of the 
lymphatic glands is an indication of syphilis, while regional infection 
speaks in favor of tuberculosis. A gumma of the tongue is not infre- 
quently the starting-point of a carcinoma. This complication must 
therefore be looked for in syphilis of the tongue. If any doubt exists 
as to the differential diagnosis of carcinoma and syphilis, examination 
of a section of the tumor under 
the microscope will clear up the 
uncertainty. In actinomycosis of 
the tongue the discovery of acti- 
nomyces under the microscope 
will render the diagnosis positive. 

The prognosis of carcinoma 
of the tongue is always grave. 
Many of the reported perma- 
nent cures effected by operation 
were undoubtedly cases in which 
a gumma was mistaken for a 
carcinoma. Billroth and Kocher 
claim that the results after op- 
erations for carcinoma of the 
tongue are as favorable as those 
after operations for carcinoma of 
other organs. Winiwarter's sta- 
tistics show that the mortality 
of extirpation of the tongue, 
which formerly was very great, 
has been reduced to 17.6 per 
cent. The diagnosis should be 
made early, and useless treat- 
ment by the application of caus- 
tics, etc. should give way to an 
early and thorough operation. 

Radical Operations for Carcinoma of the Tongue. — In all operations 
upon the tongue it is very important to disinfect the whole cavity of the 
mouth, as advised by Billroth. The fear of hemorrhage has in the past 
induced surgeons to substitute for the knife and scissors the ecraseur or 
the galvano-caustic wire. The employment of these instruments did not 
always prevent hemorrhage when the tongue was amputated near its base, 
and for this and other substantial reasons they have almost entirely been 
abandoned. Mr. Hutchinson continues to use the ecraseur, but he has 
few imitators. In all operations on the tongue the organ should be 




Fig. 173.- 



Syphilitic nodule and fissure of the tongue 
(after W. Fairlie Clarke). 



292 



PATHOLOGY AND TREATMENT OF TUMORS. 



pierced in the middle line near the tip with a large needle armed with 
heavy silk. With this thread, which is tied at the end, the tongue can 
be drawn and held in any direction during the operation. Preliminary 
ligation of one or of both lingual arteries as a prophylactic measure 

against hemorrhage is seldom prac- 
tised at the present time, and is 
not to be recommended. Some sur- 
geons employ temporary hemostatic 





Fig. 174. — Temporary constriction of one-half of the 
tongue (after Esmarch and Kowalzig). 



Fig. 175. — Temporary constriction of the whole 
tongue at its base (after Esmarch and Kowalzig). 



measures during the operation (Figs. 174, 175). In applying temporary 
constriction the tongue is pierced in the middle at its base with a large 
needle armed with a long and strong silk suture. If it is the intention 
to constrict only one side, the needle is liberated and the suture is tied ; 
if the whole tongue is to be rendered bloodless, the thread is cut near 
the needle and the two threads are tied on opposite sides. The writer 
has tunnelled the base of the tongue in the middle line with a small 
pair of hemostatic forceps, and has drawn through the tunnel a small 
rubber tube about twelve inches in length, cut it in the middle, and 
constricted each side by tying the rubber ligatures firmly enough to 
interrupt both the arterial and the venous circulation. This method 
of elastic constriction is to be preferred to the use of silk ligatures. 
If the surgeon has reliable assistants, preliminary elastic constriction is 
unnecessary, even if the entire tongue is to be removed. 

If the tumor is small and can be removed effectually through the 
mouth by a wedge-shaped excision, the tongue is rendered accessible 
by the use of Whitehead's gag. The operation through the mouth is 
applicable when the tumor occupies the anterior third of the tongue. 
The line of incision should be made at least three-quarters of an inch 
distant from the palpable margin of the tumor. The thread with which 
the tongue is drawn forward is inserted in such a manner that it can be 



CARCINOMA. 



293 



used as a suture after excision of the tumor (Figs. 176-179). After the 
tongue has been drawn well forward the excision is made either with 





Fig. 176. — Insertion of traction-suture 
(after Esmarch). 



Fig. 177. — Excision of tumor (after Esmarch). 



the knife or with scissors. The hemorrhage is readily controlled by 
accurate suturing. The deep sutures should include all the tissues, 
and if there is any tendency to inversion of the mucous membrane, this 





Fig. 178. — Tying of first suture (after Esmarch). Fig, 179. — Operation completed (after Esmarch). 

tendency should be averted by the use of a few superficial fine catgut 
sutures. 

Whitehead removes the entire tongue through the mouth with 
scissors, and immediately grasps and ties the lingual arteries. Few 
surgeons perform Whitehead's operation — not because it is difficult and 
cannot be done safely, but because cases which require amputation of 
the entire tongue are complicated by regional infection, the treatment 
of which requires an external incision. Langenbeck makes an incision 
from the angle of the mouth downward, and divides the inferior maxilla 
transversely in the line of the external incision (Fig. 1S0). The ends 
of the bone are then drawn apart sufficiently to secure free access 
to the base of the tongue. After completion of the amputation the 
bone-ends are brought in apposition and are sutured with silver wire. 



294 



PATHOLOGY AND TREATMENT OF TUMORS. 



Regnoli devised an operation, later modified by Billroth (Fig. 181), 
by which the base of the tongue can be made freely accessible without 
dividing the inferior maxilla. The cavity of the mouth is opened by a 
horseshoe-shaped incision corresponding with the lower border of the 

jaw; the cavity of the mouth 
being opened, the tongue is 
drawn forward through the in- 
cision sufficiently to bring its 
base within easy reach. More 
recently, Kocher devised an 
incision by which the base of 
the tongue is reached from the 
side without dividing the jaw 
(Fig. 182). This incision is com- 
menced below the ear, and is 
carried along the anterior mar- 
gin of the sterno-cleido-mastoid 
muscle about five inches, when 
it is directed forward, and by a 
small turn upward is made to terminate near the symphysis of the chin. 
The flap of skin is then raised as far as the lower border of the jaw, and 
through this space the base of the tongue is reached. The tongue is 
then drawn through the incision and is amputated in the usual manner. 




180. — Amputation of the tongue by Langenbeck's 
method. 





Fig, 181. — Amputation of the tongue according 
to Regnoli-Billroth. 



Fig. 182. — Kocher's incision in amputation of the 



tongue. 



Kocher's incision affords the surgeon an excellent opportunity to remove 
all the submaxillary and submental lymphatic glands, but does not expose 
the base of the tongue as freely as the Regnoli-Billroth method. From 
experience the writer is satisfied that the Kocher method is well adapted 
for partial removal of the tongue, but when the entire organ is to be 



e 



CARCINOMA. 295 

amputated the Regnoli-Billroth method deserves the preference. After 
the tongue has been drawn well forward, before making the amputation, 
it has been the habit of the writer to insert on each side of the base of 
the tongue an additional traction-suture, with which to control th 
stump later. This is an exceedingly important precaution. After 
dividing the tongue by one stroke of the knife as far as the median 
line, the lingual artery is grasped and tied. The lingual artery on the 
opposite side is dealt with in a similar manner after the amputation has 
been completed. The parenchymatous oozing is moderate, and is con- 
trolled by suturing the stump. It is advisable to remove as much of 
the floor of the mouth as necessaiy, and all the infected lymphatic 
glands, before the tongue is amputated. The writer always resorts to 
partial anesthesia in performing the operation, for the purpose of 
securing the patient's co-operation in preventing the entrance of blood 
into the larynx. The two traction sutures are brought out of the 
mouth, and are used in fixing the stump in proper position for a day 
or two after operation. The wound is covered with adhesive iodoform 
gauze or with Whitehead's benzoe mixture. The external wound is 
closed except at a point best adapted for drainage. If necessary, the 
patient is nourished for a few days by introducing food into the stomach 
through an elastic tube or by rectal feeding. A saturated solution of 
boric acid should be used frequently as a gargle or mouth-wash. Care- 
ful attention in the after-treatment is of great importance in the preven- 
tion of acute pulmonary complications. The functional results are 
satisfactory after complete extirpation of the tongue. It has been 
ascertained that the criminals in Persia who were formerly punished by 
cutting out of the tongue recovered speech sufficiently to make them- 
selves understood. The same has been observed after amputation of 
the entire tongue for carcinoma. The function of deglutition is pre- 
served almost to perfection. 

Parotid. — Carcinoma of the parotid gland does not occur in persons 
less than forty years of age. Carcinoma of the salivary glands is 
notoriously malignant. The acinous variety begins as a proliferation of 
the columnar epithelia of an isolated embryonic lobule of the gland 
(Fig. 183). The stroma is usually scanty in this variety. The tumor 
grows rapidly and gives rise to early lymphatic infection. Weber 
described a form of carcinoma of the parotid that closely resembles 
hard carcinoma of the breast. The tubular variety begins in the distal 
branches of the salivary duct, in the form of epithelial pearls of colum- 
nar epithelial cells which arrange themselves in the form of tubules, 
which multiply and grow into the substance of the gland. A rapid- 
growing tumor of the parotid gland in a person fifty or more years 



296 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 183. — Adenomatous stage of a cancer of the 
submaxillary gland ; X 35° (after D. J. Hamilton) : a, 
section of a normal acinus ; b, an acinus distended with 
proliferating epithelium : other parts of the gland were 
completely cancerous. 



of age is, with very few exceptions indeed, a carcinoma. The capsule 
of the gland is perforated at an early stage, when the tumor involves 

the overlying skin and the neigh- 
boring organs. The external 
ear, the malar bone, and the 
ascending ramus of the inferior 
maxilla are frequently impli- 
cated. In two cases that have 
come under the writer's obser- 
vation paralysis of the facial 
nerve existed at the time the 
operation was performed. Re- 
gional infection extends to the 
deep lymphatics of the neck. 

Extirpation of the Parotid- 
Gland. — Extirpation of the par- 
otid gland was first performed in 
America in 1804 by the father 
of J. Collins Warren. Brainard 
of Chicago performed the opera- 
tion a number of times, and 
strongly maintained its feasibility. Konig advises in the aged a 
partial excision of the gland, with a view of preventing facial paral- 
ysis if the tumor is not large. The writer is of the opinion that 
partial removal of the parotid gland for carcinoma is an unjustifiable 
and unsurgical procedure, as recurrence is sure to take place, and the 
recurrent tumor grows more rapidly than the primary growth. Carci- 
noma of the parotid gland indicates complete removal of the gland with 
all other infected tissues, and is always followed by permanent facial 
paralysis. The writer has removed the parotid gland for carcinoma 
six times without a death, and has never observed serious consequences 
from the facial paralysis. In one case there was removed, in addition to 
the tumor, the entire external ear ; in another, the malar bone and part 
of the superior maxilla ; and in a third, the ascending ramus of the in- 
ferior maxilla with the parotid. The overlying skin is generally found 
affected, and must be excised with the tumor. Preliminary ligation 
of the external or common carotid artery is unnecessary, as the external 
carotid artery can be ligated in the wound toward the completion of the 
operation. Liston and Dieffenbach recommended intracapsular enucle- 
ation. Roser removed the carcinomatous parotid gland piecemeal 
(morcellement). 

The capsule of the gland should invariably be removed with the 



CARCINOMA. 2( 

tumor. If a large area of skin has to be excised, the part to 1 
removed should be included between two elliptical incisions, the low 
angle of the ellipse corresponding with the point where the extern 
carotid artery is to be ligated. The temporal artery is ligated on tl 
distal side and is secured by compression-forceps on the proximal sic 
The whole mass is carefully dissected all around ; the dissection mu 
be extended to the styloid process of the temporal bone. As soon 
the external carotid artery comes in view it is isolated and is graspi 
with a pair of hemostatic forceps, the tumor is removed, and the arte 
is tied. The wound-surface being large, it is necessary to cover it 1 
a plastic operation, which can be done by taking a pedunculated fl; 
from the forehead or the scalp. The scalp defect is then covered wi 
Thiersch's grafts. In the case in which the writer had to remove tl 
external ear with the parotid a little opening was made in the Ian 
skin-flap, this opening corresponding with the location of the extern 
meatus, and thus the function of hearing was preserved almost 
perfection. 

If the skin over the tumor can be preserved, the writer exposes t 
parotid gland by a curved incision, with the convexity directed dow 
ward, extending from the mastoid process to near the malar prominenc 
turns this flap upward, and then proceeds to remove the tumor as h 
been described. The results after this operation compare favorab 
with those of removal of the breast for carcinoma. If the deep cervic 
elands are infected, the incision must be extended downward aloi 
the anterior border of the sterno-cleido-mastoid muscle. Carciuot 
of the parotid gland sliould be removed as early and as thoroughly 
possible, and the patient must be made to understand that the price 
pays for a radical operation includes invariably a permanent fac, 
paralysis. 

Thyroid. — Carcinoma of the thyroid gland is very rare in t 
United States. Malignant disease of this gland is usually associat 
with adenoma or with miasmatic struma, and is consequently mc 
prevalent in localities where these affections are endemic. Carcinor 
of the thyroid gland presents an additional interest from the fact tl 
such tumors are by no means limited to the thyroid gland. Accessc 
thyroid glands are quite frequently found in the neighborhood of t 
thyroid, but thyroid tissue has a much more diffuse distribution 
different parts of the body. It has been found in the bronchial glam 
in the lungs, and in the bones in cases where the thyroid was enlargf 
and its presence in these situations has been regarded as an exam; 
of metastasis. According to Piana, thyroid tissue occurs close to t 
aortic arch in the dog. The hyoid glands of Zuckerkandl and Kad 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 184. — Microscopical ap- 
pearance of pulsatile tumor of the 
skull (after Morris). 

the tumor immovable. 



which are well described by Streckeisen, consist of remains of the 
thyroid duct and of gland-tissue, and may become the seat of malig- 
nant as well as benign tumors. 

Heterotopic tumors composed of thyroid tissue are excessively rare. 
Morris in 1880 described a case of pulsatile tumor of the skull in which 
it was shown under the microscope that the 
tumor was composed of thyroid tissue (Fig. 
184). Coats reported a similar case. Gussen- 
bauer found such a tumor in the vertebras. 
That such a matrix should occasionally serve as 
a starting-point of carcinoma should be remem- 
bered when a primary carcinoma is found in 
tissues normally devoid of epithelial cells. 

Carcinoma of the thyroid gland is met with 
most frequently in persons from thirty to fifty 
years of age. The tumor infiltrates the gland- 
tissue, and soon perforates the capsule and 
extends to the surrounding tissues, rendering 
Extension in the direction of the trachea gives 
rise to hoarseness and dyspnea. Destruction of the recurrent laryngeal 
nerves results in paralysis of the vocal cords. Wolfler describes a 
malignant adenoma of the thyroid gland — a tumor which under the 
microscope exhibited the same appearances as an adenoma, but which 
clinically pursued the same course as carcinoma. Histologically he 
recognizes three varieties: 1. Alveolar carcinoma; 2. Cylindrical-celled 
carcinoma; 3. Squamous-celled carcinoma. 

Carcinoma of the thyroid usually proves fatal within a year. It 
starts most frequently in a pre-existing miasmatic struma or adenoma. 
If a goitre that has remained stationary for a long time commences to 
increase rapidly in size without any apparent cause, it is more than prob- 
able that it has become the scat of a carcinoma, either by the tissues 
composing the pre-existing pathological product having undergone malig- 
nant transformation, or from the development of a carcinoma from a 
separate matrix of embryonic cells within or in the immediate vicinity of 
the infective swelling or the benign tumor. Kaufmann recommended as 
a means of early and positive diagnosis puncture of the tumor and exam- 
ination under the microscope of fragments of tissue removed in this way. 
Extirpation of the Thyroid Gland for Carcinoma. — The only surgical 
treatment of carcinoma of the thyroid gland is early and thorough excis- 
ion. The removal of a carcinomatous tumor of this gland is a much 
more difficult task than the enucleation of an adenoma or a cyst, as the 
tumor has usually perforated the capsule of the gland before the opera- 



CARCINOMA. 



299 



tion is undertaken. The excision of a carcinoma of the thyroid gland 
necessitates ligation of numerous and large veins (Figs. 185, 186). A 




Fig. 185. — Tumor of the right lobe of the thyroid 
gland, showing ramification of superficial veins 
(after Kocher). 




'"Ill 



Fig. 186. — Schema showing points of ligation of 
large veins in extirpation of thyroid tumors (after 



Kocher). 



curved transverse incision with the convexity directed downward will 

afford the best access to the base of the tumor. The large veins should 

be divided between a double ligature. A very useful instrument in 

making the dissection is Kocher's director (Fig. 187). 

Venous hemorrhage is more to be feared than arterial 

hemorrhage, and is more difficult to control. Injury to 

the recurrent laryngeal nerve has frequently happened 

during operations for malignant disease of the thyroid. 

Permanent paralysis of the vocal cord on the same side 

is a constant result of this accident. If the trachea 

has become involved, it is generally opened during the 

operation, and a tracheal cannula should be inserted at 

once. 

The results of operations for malignant disease of the 
thyroid gland have not been very encouraging. Local 
recurrence is the rule, even if the infected lymphatics are 
carefully removed with the tumor. The operation, how- 
ever, is one of great palliative value, and is the only means 
of preventing death from suffocation. In operating for 
malignant disease of the thyroid the whole gland should 
be removed, as it is much better for the patient to run the risk of 



Fig. r87. — Kocher'^ 
director. 



300 PA THOLOG V AND TREA TMENT OF TUMORS. 

becoming later the subject of cachexia strumipriva than to take the 
chances of an early local recurrence. 

Mammary Gland. — The greatest interest centres in carcinoma of the 
mammary gland, owing to the great frequency with which this organ is 



l tS » 



I 




M ' n K -fir* *Of~S ' } 

HHPt ' 

1 11 r " sn^ « 



ill • " 'l^fiSJt^ 








^M 







IBil 



tt 



Ik 

OH WB1 



A 



Fig. 188. — From carcinoma of mammary gland, showing Infiltration of connective-tissue spaces with 
carcinoma-cells: connective-tissue endothelia can be seen in places lining the connective-tissue spaces; 
X 250 (after Ziesing). 

affected. The frequency of carcinoma as compared with other tumors 
of the breast is very great, as Billroth found in 440 tumors of the breast 
that only in 18 per cent, were the tumors of a non-malignant character. 



CARCINOMA. 



3 QI 



.^0%@$lm 






mmmm 



mmm 




Fig. 189. — Acinous carcinoma of mammary gland ; X "°, reduced one-third (Surgical Clinic, Rush 
Medical College, Chicago) : a, connective-tissue stroma; b, tumor-parenchyma; c, blood-vessels in stroma; 
(/, wandering carcinoma-cells ; e, area where recent hemorrhage has occurred ; f, blood-pigment ; g, shrink- 
age in hardening. 

Histological Varieties. — The histological structure of a carcinoma of 
the mammary gland depends on the type of cells of which it is com- 




KiG. ioo.-Alveolar carcinoma of breast (after Kunig); a, alveoli filled with epithelial cells ; b, empty alve- 
oli ; c, stroma infiltrated in places by small round cells. 



302 



PATHOLOGY AND TREATMENT OF TUMORS. 



posed and the amount and arrangement of its stroma. The embryonic 
matrix from which it develops is always derived from the epiblast, but 




Fig. 191. — Tubular carcinoma in cystic tumor of the breast ; natural size (Surgical Clinic, St. Joseph's 
Hospital, Chicago): a, tumor; b, pedicle ; c, cavity of cyst ; ^normal gland-tissue; e, adipose tissue;/", 
pin supporting tumor. 

the morphology of the cells is determined by the part of the gland 
which the matrix represents. The product of tissue-proliferation rep- 
resents either the acinous or the duct portion of the gland. 




Fig. 192.— Section from tumor shown in Figure 191 ; X 185 : a, alveolated stroma infiltrated in some places 
by small cells ; b, columnar epithelial cells filling tubular spaces. 

Acinous Variety. — In this variety the cells are packed in the alveoli 
of the stroma very much in the same manner as in carcinoma of the 



CARCINOMA. 



303 



skin (Fig. 189). If the alveoli are large, we speak of "alveolar carci- 
noma," although the stroma of all carcinomatous tumors presents an 
alveolated structure (Fig. 190). If the parenchyma of the tumor pre- 
dominates greath' over its connective-tissue stroma, the tumor is soft and 
very vascular, corresponding with what was formerly called "enceph- 
aloid " or " medullary " cancer. If the tumor is hard and nodulated, 
it answers to what is still being described as "scirrhus." If the cellular 
elements or the stroma, or both, undergo such extensive colloid degen- 
eration that the tumor is largely composed of colloid material, it has 
been customary to call such a tumor a " colloid cancer." In acinous 
carcinoma of the mammary gland the cells infiltrate the connective- 
tissue spaces around the primary growth, and the tumor increases in 
size (Fig. 188). 

Tubular Variety. — Tubular carcinoma frequently takes its starting- 
point in a pre-existing cystic disease of the ducts of the gland. The 
cells are either columnar or resemble columnar cells which line duct- 
spaces or infiltrate the connective-tissue stroma (see Plate 4). Tubular 
carcinoma is less malignant than the acinous variety. In one case the 
writer found in the breast of a woman thirty-five years old a tubular 
carcinoma which had existed for six months, and during this time it 
had reached the size of a walnut. The skin over the tumor remained 
unaffected, and the nipple was not retracted. Distinct fluctuation was 
felt. The cyst was excised. On laying it open a small quantity of 
mucoid material escaped. The 
interior of the cyst was occupied 
by a pedunculated papillary tu- 
mor (Fig. 191). Dr. Mellish, 
who examined the tumor and 
made the drawings, traced its 
pedicle to the orifice of a duct- 
like tract in the gland-tissue. 
This blind tract could be fol- 
lowed to the depth of about a 
quarter of an inch into the 
substance of the gland. There 
is no doubt that the tumor 
developed from the wall of a 
pre-existing duct, and that it 
caused by its presence in- 
creased secretion and retention of the secretions which produced the 
cyst. Sections of the tumor showed a well-marked alveolated struc- 
ture of its stroma, its spaces filled with columnar epithelial cells. 




Fig. 193. — Tubular form of carcinoma of the breast : infil- 
tration of the stroma by small round cells (after Konig). 



304 PATHOLOGY AND TREATMENT OF TUMORS. 

In typical tubular carcinoma the tubular arrangement is preserved 
in the new portions of the tumor. The membrana propria, however, is 
defective in many places and permits the infiltration of the stroma by 
new cells (Fig. 193). 

Etiology. — Very little is known concerning the exciting causes of car- 
cinoma of the breast. It occurs most frequently in women past thirty- 
five years of age ; the soft variety is more frequent in young persons, and 
the hard variety in persons advanced in years. The rarity of the occur- 
rence of carcinoma in men points to the frequently-recurring hyperemia 
of the mammary gland in females during pregnancy, lactation, and 
menstruation as an important etiological factor. That pregnancy and 
lactation are important causes is shown from the fact that in carcinoma 
of the breast in the female the proportion of the unmarried to the mar- 
ried, according to Bryant, is 1:33-; according to Baker, of 260 cases, 
23 per cent, occurred in single and 72 per cent, in married women, and 
4 per cent, in widows. In a small percentage of cases the disease had 
evidently a traumatic origin. Antecedent lesions of the breast, abscess, 
fissure of the nipple, and eczema appear to have acted as exciting 
causes or to have furnished besides the essential tumor-matrix. Occa- 
sionally an adenoma undergoes malignant transformation. The etio- 
logical relation between eczema of the nipple and carcinoma of the 
breast is now generally recognized. In a case that came under the 
writer's observation the eczema preceded the carcinoma by over five 
years, and during this time no evidences of the carcinomatous nature 
of the primary skin affection could be detected by the most careful 
and frequently-repeated examinations. 

In 1874, Sir James Paget read a paper in which he discussed for the 
first time the connection of eczema of the areola of the breast with 
carcinoma, basing his remarks on fifteen cases which had up to that 
time come under his personal notice. Some of his remarks on this 
subject are quoted: "The patients were all women various in age, 
from forty to sixty or more years, having in common nothing remark- 
able but their disease. In all of them the disease began as an eruption 
on the nipple and areola. In the majority it had the appearance of a 
florid, intensely red, raw surface, very finely granular, as if nearly the 
whole thickness of the epidermis were removed — like the surface of 
very acute diffuse eczema or like that of an acute balanitis. From such 
a surface, on the whole or greater part of the nipple and areola, there 
was always a copious, clear, yellowish, viscid exudation. The sensa- 
tions were commonly tinglings, itching, and burning, but the malady 
was never attended by disturbance of the general health. I have not 
seen this form of eruption extend beyond the areola, and only once 



CARCINOMA. 305 

have seen it pass into a deeper ulceration of the skin after the manner 
of a rodent ulcer. In some of the cases the eruption has presented the 
characteristics of an ordinary chronic eczema, with minute vesications, 
succeeded by soft, moist, yellowish scabs or scales and constant viscid 
exudation. In some it has been like psoriasis, dry, with a few white 
scales desquamating, and in both these forms, especially the psoriasis, 
I have seen the eruption spreading far beyond the areola in widening 
circles, or with scattered blotches of redness covering nearly the whole 

breast But it has happened that in every case which I have been 

able to watch cancer of the mammary gland has followed within at the 
most two years, and usually within one year. The formation of cancer 
has not in any case taken place first in the diseased part of the skin. 
It has always been in the substance of the mammary gland, beneath or 
not far from the diseased skin, and always with a clear interval of appar- 
ently healthy tissue." 

In view of the fact that eczema of the nipple is so constantly fol- 
lowed by carcinoma, and as the disease appears to resist all kinds of 
local treatment, Paget is in favor of early operative removal of the dis- 
eased breast as the only known prophylactic measure against carcinoma 
from this source. 

Thin, who studied Paget's disease of the nipple from a histological 
standpoint, found first the skin of the nipple eczematous. The inflam- 
matory process creeps then along the mucous membrane of the milk- 
ducts. Bryant estimates that carcinoma of the breast is hereditary in 
10 per cent, of all cases. Sprengel traced a hereditary influence in 
thirteen out of 109 cases. 

Symptoms and Diagnosis. — The acinous variety of carcinoma, by far 
the most frequent, commences as a hard nodule in the substance of the 
breast, most frequently near the periphery of the organ. If the tumor 
starts in an accessory mammary gland, it usually occupies primarily 
the base of the axillary space. The tumor is nodulated, and a certain 
degree of fixity can be detected almost from the beginning. 

Tubular carcinoma starts more commonly nearer the nipple. As the 
tumor increases in size it approaches the surface : the skin is drawn 
inward, and soon becomes discolored in the centre — a condition which 
precedes ulceration. In soft tumors nodulation is less marked than in 
the hard variety, and the tumor closely resembles a sarcoma. Exten- 
sive fatty degeneration of the centre of the tumor and contraction of 
the stroma at this point leads to a depression which is often noticeable 
on the surface of the skin. Retraction of the nipple accompanies a 
similar condition, and is therefore most constant and well marked in 
hard carcinoma. It is the result of cicatricial contraction of the stroma, 
20 



306 



PATHOLOGY AND TREATMENT OF TUMORS. 



which exerts traction upon the milk-ducts. A serous or sanguineous 
fluid can sometimes be pressed from the nipple, especially in cases of 
soft tumors. Soft tumors grow rapidly, being most malignant ; the 
local infection spreads rapidly, the stroma being scanty, and the cells 
undergo early degenerative changes, especially of a colloid charac- 
ter. The tumor is soft, fluctuating, and resembles closely a subacute 
abscess or a rapid-growing sarcoma. Mr. Heath reports such a case : 
A few months before the examination the patient, a married woman 
twenty-four years of age, noticed in the left breast a swelling the size 




a,-w-5 



Tig. 194. — The lymphatics from the nipple to the axilla, placed upon the axillary vein, whence they 
mount to the under part of the clavicle, passing through an opening to terminate in the angle of the conjoined 
jugular and subclavian veins of the right side, at the lower part of the neck (after Astley Cooper): a, the 
nipple, with two absorbents from it passing upon the fourth rib, and then dividing into numerous branches 
which cover the intercostal spaces up to the third and down to the fifth rib ; they then mount to the third rib, 
to the axillary vein ib), and pass on the inner side of that vein under the clavicle (e), where they are con- 
tinued, through the opening, into the angle of the jugular and subclavian veins ; d, the subclavian artery ; 
e, e, axillary plexus of nerves. 

of a hen's egg. The tumor developed rapidly without pain, and occa- 
sionally blood flowed from the nipple. A little later, in consequence 
of the large size of the breast and the copious discharge of blood from 
the nipple, she consulted Mr. Heath, who evacuated about a pint of a 
thin bloody fluid and injected tincture of iodine. This treatment was 
repeated on two other occasions. A few months later the breast was 



CARCINOMA. 



3°7 



removed. At this time there was at the site of puncture a fungous 
growth through which bloody, offensive fluid was escaping. 

Simmonds has shown that colloid degeneration cannot occur inde- 
pendently of epithelial cells. When the cells undergo this process the 
stroma can take part, and in this manner greater or lesser portions of 
rapid-growing carcinoma are transformed into colloid material. In 
the atrophic form of carcinoma the stroma is very abundant, and the 
tumor in the central part shrinks because of the partial or total disap- 
pearance of the epithelial cells by fatty degeneration and because of 
the shrinkage of the massive stroma, which in itself favors fatty degen- 
eration by causing pressure and by diminishing the blood-supply. In 
nearly all cases which come under the notice of the surgeon glandular 
infection has already occurred. It may be impossible to detect the 
enlarged glands through the intact skin, 
especially in obese women, but their exist- 
ence can generally be demonstrated at the 
operation. 

The relation of the lymphatics to the 
mammary gland and their location and dis- 
tribution are well shown in Figures 194, 
195. 

The lymphatic glands nearest the 
mammary gland usually become affected 
first, when the regional infection ex- 
tends in the direction of the apex of 
the axillary space. The glandular tu- 
mors are often more numerous than the 
normal glands, and some of them are 
tumors which have developed in the lym- 
phatic vessels. The enlargement of the 
lymphatic glands belonging to the bra- 
chial lymphatics produces cedema of the 
arm — a condition which becomes aggra- 
vated by pressure of the tumors upon the 
axillary vein. Lymphatic enlargement 
usually takes place along the greater 
pectoral muscle, but, as pointed out by 
Astley Cooper, if the tumor is on the 
sternal side of the nipple, the supracla- 
vicular glands become involved by way 
of the internal mammary lymphatics. Metastasis takes place most 
frequently in the liver; next in frequency come the lungs, the pleura, 




Fig. 195, — Shows the lymphatics (a) 
of Figure 194 passing under the blood- 
vessels (fr), the axillary vein (tr), the artery, 
across four of the upper ribs, joining with 
the anterior, entering the angle of the 
jugular and subclavian of the right side 
at d (after Astley Cooper). 



3 o8 



PATHOLOGY AND TREATMENT OF TUMORS. 



and the brain. Torok and Wittelshofer have found metastasis in the 
bones of the skull. Metastatic tumors of the long bones frequently 
result in pathological fracture. Carcinoma of the vertebrae resembles 
clinically spondylitis. Billroth and Konig have observed metastasis 
most frequently in connection with slow-growing hard carcinoma, 
which corresponds with the results of the writer's observations. 

In the hard variety the ulcer is at first superficial, and extends 
primarily more toward its periphery than in the direction of the tumor. 




Fig. 196. — Carcinoma of the breast. 

In soft carcinoma the superficial ulceration often gives rise to central 
sloughing of a considerable portion of the tumor; this sloughing, upon 
separation of the gangrenous part, leaves a crater-like excavation. 
Infection with pus-microbes hastens the destructive process, and the 
presence of putrefactive bacilli in the dead tissues causes putrefaction, 
which is the source of the offensive odor which characterizes the dis- 
charge from soft carcinoma of the breast. Patients who have remained 
in good health until ulceration begins soon become cachectic from 
the absorption of septic material from the surface of the tumor and 
from the inflamed tissues. Pain may be almost entirely absent in 
soft carcinoma of the breast, the disease resembling in this respect 
sarcoma. In the hard variety the pain, of a shooting or lancinat- 
ing character, is always present after the tumor has attained a cer- 
tain size, but is variable in its intensity ; it is always intermittent, 
and is apt to be aggravated during the night and after active 
exercise. 

A rapid-growing tumor of the breast is a malignant tumor. To 
determine whether the enlargement of the breast is caused by an infec- 



CARCINOMA. 



309 



tive swelling or by a tumor requires often a very careful examination. 
A subacute suppurative mastitis often resembles in its signs and symp- 
toms a malignant tumor. The clinical history must be investigated 
carefully and all possible sources of infection be ascertained. If any 
doubt remain, an opinion should not be given until after an exploratory 
puncture has been made. 

Tuberculosis of the breast often presents itself as a multiple affec- 
tion, which is not the case in carcinoma. An adenoma without cystic 
degeneration hardly ever exceeds in size a walnut. Cystoma forms 
very slowly, fluctuates on palpation, and upon deep pressure offers a 




Fig. 197. — Adenoma of the breast ; X 75 (Surgical Clinic, Rush Medical College, Chicago) : a, massive 
connective-tissue stroma ; 6, gland-ducts cut transversely ; c, gland-ducts cut obliquely; ^.cystic dilatation 
of duct. 



sense of elastic resistance. It is important to distinguish between sar- 
coma and carcinoma before an operation is undertaken, as the operative 
procedure will depend to a certain extent on the diagnosis. Sarcoma, 
as a rule, grows more rapidly than the hard variety of carcinoma. It 
appears as a smooth tumor, and it is seldom complicated by infection 
of the axillary glands. It occurs in persons of all ages, while carci- 
noma is seldom met with in women less than thirty years of age. 



3IO PATHOLOGY AND TREATMENT OF TUMORS. 

The examination of a section taken from the tumor under the 
microscope will enable the surgeon to make a differential diagnosis 
between adenoma (Fig. 197), carcinoma, and sarcoma. In adenoma 
the stroma is massive and the epithelial cells are limited to the space 
inside the membrana propria. A glance at Figure 198 will be sufficient 
to distinguish carcinoma from an adenoma. The epithelial cells here 
are limited to no one particular place, but are found everywhere and 
in direct contact with the vascular connective tissue. 

Round-celled sarcoma of the breast, so far as the appearances of the 
tumor are concerned, very closely simulates the soft form of carcinoma. 
Under the microscope it is distinguished from the latter by the absence 
of a well-marked alveolar stroma, by the more uniform distribution of 
the cells, and by the sarcoma-tissue forming a part of the wall of the 
new blood-vessels (Fig. 199). The displacement of the gland-tissue by 
traction and by projecting parts of the tumor in carcinoma distinguishes 
this tumor from all other pathological products. Paget aptly says : 
" Moreover, mere indurations do not involve the skin, do not invade or 
infiltrate it, or produce in it any puckering or dimpling, as by drawing 
a part of it toward their own mass. In this, indeed, I think there may 
be an almost unfailing diagnostic sign." 

Another important diagnostic feature of carcinoma that distin- 
guishes it from all other tumors is its peculiar dissemination through 
the lymphatics of the skin after the tumor has reached the surface. 
Billroth has likened this to the manner of dissemination of papular 
exanthemata. Nodules appear in the skin in the vicinity of a carci- 
nomatous ulcer, and feel like shot under the epidermis. They rapidly 
increase in number in all directions. The lymphatic channels are impli- 
cated, and the whole surface, if the disease spreads rapidly, presents 
an erysipelatous appearance. So long as the nodules remain isolated, 
Velpeau called this condition sqidrrhe dissemine'e ou pustuleux, and 
when the nodules become united into a board-like mass, squirrhe en 
masse. 

Cicatricial contraction is a prominent feature of this form of sec- 
ondary carcinoma of the skin. The lymphatic vessels play here a 
more important part in the dissemination of the carcinotfla than do the 
lymphatic glands. Carcinoma of the superficial lymphatics appears to 
be, if the expression be allowed, a carcinomatous lymphangitis. In 
some cases the deep carcinoma becomes adherent to the chest-wall and 
continues to contract, but at the same time continues to extend after 
reaching the gland in the opposite side. The chest-wall becomes fixed 
and respiration becomes difficult. The whole wall of thorax on the 
affected side is rendered immovable, board-like ; this condition was called 



CARCINOMA 




312 PATHOLOGY AND TREATMENT OF TUMORS. 

by Velpeau cancer en atirasse. Cancer en cuirasse is not a distinct 
anatomico-pathological or clinical form of carcinoma, as was formerly 
asserted, but is always the result of the extension of a glandular carci- 
noma to the lymphatics of the skin. The writer has never observed it as 
a primary affection. It is a rather frequent complication of neglected 
carcinoma or of recurrent carcinoma of the breast, and is another form 
of regional infection, occurring later than regional infection through the 
deep lymphatic glands. When the tumor has reached this stage it is 
usually inoperable. Recurrence is almost sure to follow most exten- 
sive operations. Infection of the superficial lymphatics of the skin 
appears often in such an acute form that the temperature rises several 
degrees above normal, and in a few weeks the whole side of the chest 
becomes involved. New nodules appear every day, and the skin during 
the acute stage presents an erysipelatous blush. 

In the rudimentary mammary gland in men occur nearly all the 
tumors that have been observed in the female, especially carcinoma. 
Schuchhardt recently collected 277 cases of carcinoma of the breast in 
males. When carcinoma develops in the male breast, it follows the 
same clinical course as in the female. Regional and general infection 
occur with equal frequency, and the disease proves fatal in about the 
same length of time as in the female. 

Prognosis. — Birkett estimated the average duration of life of patients 
suffering from carcinoma of the breast, and upon whom no operation 
is performed, as being three and a half years. The duration of the 
disease is affected very much by the age and the constitution of the 
patient, the course being slower in the older and less plethoric patients. 
Astley Cooper's estimate is a fair one — namely, two years for the full 
development of the disease, and from six months to two years longer 
for a fatal .termination. In some instances, particularly in the aged, 
the disease pursues a very slow course, extending over a period of 
from six to fifteen years. In a case of pathological fracture of the 
upper part of the femur in a woman seventy-five years of age the writer 
iccidentally discovered a small firm tumor in the left breast. On com- 
municating this information to the patient she stated that she had first 
discovered a small lump in the breast twenty years previously. In this 
:ase, as in many other cases which finally terminate in metastasis, the 
:umor remained in a latent condition for twenty years. 

The malignancy of carcinoma of the breast appears to diminish with 
idvancing age. Soft carcinoma, observed most frequently in the young, 
eads to a fatal termination much more rapidly than the hard variety. 
The local infection progresses more rapidly, and the tumor attains a 
arger size, in the soft than in the hard variety. Patients suffering from 



CARCINOMA. 313 

the soft form of carcinoma of the breast are frequently carried off by 
some acute chest complication, and the autopsy reveals secondary 
tumors in the lung and the pleura. Tumors which have undergone 
colloid degeneration do not result in early regional infection : they 
pursue a comparatively benign course. 

It is interesting to know what has been gained in the duration of 
life by operative treatment. Birkett estimates that patients who have 
been subjected to operative treatment live, on an average, four years, 
while the duration of life in those not operated on is three and a half 
years. Sibley, in 78 cases not operated on and in 63 operated on, 
ascertained that the latter lived one year and nine months longer 
than the former. Patients operated upon by Paget and Volkmann 
lived one year and two and a half months longer than those treated 
upon an expectant plan. According to Winiwarter, patients not ope- 
rated on live 32.9 months, and those operated on 39.3 months. A 
certain percentage of those patients subjected to operative treatment 
remain free from a recurrence. Winiwarter ascertained that most of 
the relapses — that is, 82. 4 per cent. — occur within three months after 
the operation. Relapses, however, may occur as late as ten years after 
operation. The extensive statistics of Winiwarter, Billroth, Oldekop, 
Esmarch, Henry, Breslau, Fischer, and Dennis show conclusively that 
operations undertaken before axillary infection has taken place yield 
the best results. Since surgeons have made it a rule to clear out the 
axilla in every case of carcinoma of the breast the results are becoming 
better. Dennis secured a permanent result in 25 per cent, of his cases. 
The average percentage of cases in which no recurrence takes place in 
the hands of other operators is, however, much less. The mortality 
of the operation under the influence of antiseptic measures has been 
reduced to from 5 to 7 per cent. The writer is confident that when the 
public has become educated in reference to the necessity of early 
operations, and the profession recognizes the importance of carrying 
the incisions far beyond the palpable tumor and the infected glands, 
the percentage of permanent recoveries will be increased greatly, and 
the mortality of the operation, by a strict adherence to aseptic meas- 
ures, will become reduced to 1 or 2 per cent. 

Treatment. — The palliative measures in inoperable cases of carci- 
noma consist of such measures and palliative operations as have been 
described under the head of Palliative Treatment of Carcinoma. The 
contraindications to a radical operation are : Extreme old age ; meta- 
static tumors ; local or regional extension of the disease beyond the 
limits of a justifiable radical operation; the coexistence of other dis- 
eases which would in themselves tend to destroy life in a short time. 



314 PATHOLOGY AND TREATMENT OF TUMORS. 

It is useless to emphasize what is now insisted upon by all practical 
surgeons — that a radical operation should be performed before regional 
infection has taken place. A radical operation should be performed as 
soon as a diagnosis has been made. The diagnosis should be made 
positive either before or at the time of operation. Upon the differential 
diagnosis between adenoma and carcinoma depends the thoroughness of 
the operation. An adenoma is removed by enucleation; a carcinoma 
demands the removal of the entire breast. The removal of the entire 
mammary gland for adenoma is unwarranted ; the removal of a carci- 
noma of the breast without removing the entire organ is almost sure 
to be followed by an early recurrence. If an unequivocal diagnosis of 
carcinoma is made, it is not only necessary to remove the entire breast, 
but all the connective and adipose tissue and lymphatic glands from 
the margin of the breast to the very apex of the axilla should be 
removed with the breast. The extent of a radical operation is reached 
by removing at the same time such parts of the pectoral muscles and 
the latissimus dorsi as may be deemed necessary. The removal of the 
entire upper extremity, as suggested by McGraw, and the resection of 
numerous ribs when the tumor has invaded the chest-wall, are beyond 
the limits of prudent surgery. 

The field of operation should be prepared the evening before the 
operation by scrubbing with warm water and potash soap, shaving, anc 
the energetic use of a i : iooo solution of corrosive sublimate. The 
use of alcohol or of ether is useful in removing infectious materia 
from the appendages of the skin. A compress of aseptic gauze wrung 
out of the sublimate solution should be applied, the moisture being 
retained by applying over the compress an impermeable fabric like 
gutta-percha paper, mackintosh, or oiled silk. The hands of th< 
operator and his assistants are carefully disinfected, and the instru 
ments, ligatures, and sutures are sterilized by boiling for ten minute: 
in a I per cent, solution of carbonate of soda. No antiseptics are t< 
be brought in contact with the wound. Gauze sponges should tak 
the place of marine sponges. The chest of the patient should b 
raised slightly during the operation, and the body should be incline) 
toward the opposite side. 

Unless the position of the tumor furnishes a contraindication, th 
incision should be made in such a manner as to include with the nippl 
an elliptical piece of skin, and should be carried along the border o 
the pectoralis major to the apex of the axilla (Fig. 200). The necessit 
of removal of an extensive area of skin was strongly emphasized by £ 
W. Gross. He made a circular incision around the breast and mad 
no attempt to close the wound. This course should be pursued if th 



CARCINOMA. 



3*5 



overlying skin is extensively involved, but if sufficient healthy skin 
remains, it is better to preserve enough to cover the wound. The 
hemorrhage which freely follows immediately the incision is made 
should be controlled by pressure — a duty incumbent upon the assist- 




FlG. : 



-Incision for carcinoma of the breast (after Esmarch). 



ant. The spurting arteries are then secured with compression-forceps, 
which must be relied upon as a hemostatic until the tumor and the 
axillary contents are removed, when every bleeding point is carefully 
tied with aseptic catgut. The breast with the pectoral fascia should 
be dissected out first, but should be allowed to remain in connection 
with the axillary glands. The large wound-surface is now covered 
with a compress of gauze during the dissection of the axillary space. 
If the carcinoma has extended beyond the capsule of the gland at its 
base, parts of the pectoralis major and minor and the serratus magnus 
and latissimus dorsi muscles may require removal ; but such extensive 
excision of muscular tissue as has recently been advocated by Halsted 
appears superfluous to the writer. 

The guide to the axilla is the border of the pectoralis major in front 
and the latissimus dorsi behind. It is advisable to approach the axilla 
from the front. The skin, the superficial fascia, and the panniculus 
adiposus are reflected on each side sufficiently to expose the border 
of both these muscles. After clearing the border of the pectoralis 
major the space between this muscle and the pectoralis -minor is 
inspected carefully, as a chain of enlarged lymphatics is frequently 
found in this locality. If the entire chain of glands can be removed 
by retracting the great pectoral muscle, this part of the operation is 
completed. If this cannot be done, the pectoral muscle is divided 
transversely as far as necessary, and after clearing out the axilla it is 
sutured with a row of buried catgut stitches. 



316 PATHOLOGY AND TREATMENT OF TUMORS. 

The next thing to be done is to clear the border of the lesser pec- 
toralis muscle, which at the same time serves as a guide to the axillary- 
vessels, which are the next landmarks to be sought for. The axillary 
vein can usually be found without any particular difficulty by making 
a blunt dissection with the finger, with Kocher's director, or with blunt- 
pointed scissors. Before anything is done in the apex of the axillary 
space the large vessels must be well exposed to avoid unintentional injury, 
which is unlikely to occur if the vessels are exposed and are followed 
with the requisite care. The space in front of the axillary vessels is 
next cleared out; and it is here that the chain of glands must often be 
followed and removed as far as the upper border of the first rib. This 
part of the operation must be done slowly and carefully. Rupture of 
glands by pressure or by traction must be avoided. The dissection 
here must be made with the aid of blunt instruments. A number 




Fig. 201.— Dissection of the axillary space in operation for carcinoma of the breast (after Esmarch). 

of small veins emptying into the axillary vein from below should 
be tied close to the axillary before being cut. Glands are often 
found attached to the vein, and their separation without injury to the 
vein requires patience and careful work (Fig. 201). If the vein is 
incorporated in a mass of carcinomatous glands and cannot be isolated, 
the part connected with the tumor should be removed between two 
catgut ligatures. This alternative, fortunately, does not present itself 
frequently, and resection of the vein must be avoided whenever 



CARCINOMA. 317 

possible. Small wounds of the axillary veins can safely be closed by 
lateral ligatures or by suturing, thus preserving the lumen of the vessel. 

The space behind the axillary vessels, which next claims the atten- 
tion of the surgeon, is cleared out in the same careful manner as the 
anterior space. When this has been done the dissection is continued 
in a downward direction. All spurting points are secured by hemo- 
static forceps. The preservation of the coraco-brachialis and of other 
smaller nerves traversing the axillary space, as recommended by 
Kuster, is practised only when the regional infection is slight. In the 
majority of cases it is better to excise them with the axillary contents 
than to run the risk of making an incomplete operation by preserving 
them. 

The removal of the string of glands in the direction of the sub- 
scapular artery often necessitates ligation of this vessel and its accom- 
panying vein. If the disease is at all extensive, a considerable portion 
of the serratus magnus muscle must be removed. The tumor, the adja- 
cent tissues, and the axillary contents are to be removed in one continuous 
mass. All attempts at enucleation of infected glands icill surely be fol- 
lowed by a speedy recurrence. Crushing or teasing of carcinomatous 
glands will be followed by traumatic dissemination of the carcinoma. 
As soon as the tumor and the axillary contents have been removed all 
bleeding points must be ligated. Careful kemostasis is an essential pre- 
requisite to an ideal wound-healing. 

The wound inflicted by an operation of this extent is a very large 
one, and considerable parenchymatous oozing will occur after the patient 
rallies from the immediate effects of the operation and the anesthetic. 
If the wound is sutured throughout, accumulation of a considerable 
quantity of blood and serum is almost sure to follow, often giving rise 
to painful tension, necessitating an early change of the dressing, the 
removal of one or more sutures, and the insertion of secondary sutures. 

Ordinary tubular drainage is very unsatisfactory in preventing the 
accumulation of blood in the wound. The lumen of the tube becomes 
blocked by a blood-clot, and the fluid that escapes is at the sides, and 
not through the tube. Bergmann overcame these difficulties by pack- 
ing the wound with iodoform gauze, which he removes on the second 
or third day, then closing the wound by secondary sutures. He and 
others have obtained excellent results by this treatment. The sutures 
can be inserted at the completion of the operation, but they are not 
tied until the gauze tampon is removed. In hospital practice this 
method of wound-treatment yields excellent results and is not attended 
by any additional risks of infection, but in general practice it is better 
to suture the wound and to drain with iodoform gauze. A strip of 



318 PATHOLOGY AND TREATMENT OF TUMORS. 

gauze folded upon itself several times should extend from the apex of 
the axilla to the most dependent part of the wound, where it is brought 
out through a separate incision about two inches in length. The wound 
is then sutured throughout. On the second or the third day the gauze 
drain is removed. In closing the wound the deep sutures of silk or of 
silkworm-gut are placed about an inch apart, and over them the skin is 
united accurately with a continued suture of fine catgut (PI. 6, Fig. i). 
After washing the surface with a solution of corrosive sublimate or of 
carbolic acid and drying it carefully, a copious antiseptic hygroscopic 
dressing should be applied. The line of suturing is dusted with a 
powder of iodoform and boric acid (i : 5) until the sutures are buried 
under the powder. Eight layers of iodoform gauze are applied next to 
the wound, and over the iodoform gauze a large thick compress of 
sterilized gauze. Absorbent cotton is used as a filter over and around 
the gauze, including also the shoulder. The dressing is retained by 
a wide roller composed of several layers of gauze, and the arm is 
confined to the side of the chest with the same roller bandage (PL 6, 
Fig. 2). 

The first dressing should not be changed for two or three days, 
when the gauze drain is to be removed, unless copious oozing saturates 
the dressing. When the outer dressing becomes simply stained at the 
end of the first twelve or twenty-four hours, the part stained should be 
dusted with iodoform and be covered with a thick compress of absorb- 
ent cotton retained by an additional bandage. 

The deep sutures are removed at the end of eight or ten days. At 
this time only the superficial part of the catgut suture remains. If, not- 
withstanding the strictest antiseptic precautions, infection has occurred, 
as will be indicated by a rise in the temperature on the second or the 
third day, no time should be lost in removing the dressing and some if 
not all of the sutures, and in establishing additional points of drainage. 
Antiseptic irrigation frequently repeated, and a compress kept moist 
with a saturated solution of acetate of aluminum, will then constitute 
the most important measures in the after-treatment. 

If after the completion of the operation the wound cannot be su- 
tured, the margins should be brought as close together as possible 
with tension-sutures, and the remaining surface should be paved with 
Thiersch's grafts. The results of skin-grafting performed under such 
circumstances are very encouraging. Skin-grafting enables the surgeon 
to secure primary healing of the wound under one or two dressings — a 
great gain in the management of such cases. 

After every operation for carcinoma of the breast it is important that 
the surgeon or the family physician should examine the patient every 



CARCINOMA. 



Plate 6. 





CARCINOMA. 319 

two or three months to determine whether or not a local recurrence 
has taken place. It is not a good policy to leave this matter to the 
patient or to her friends. The patient should know as little as pos- 
sible about the object of these examinations. The first nodule that is 
discovered should be removed at once. This removal can usually be 
done with the aid of a local anesthetic. Eveiy local recurrence should 
be met promptly by a thorough removal. The writer has repeatedly 
performed three and four operations for slight recurrence in the same 
patient, and has been able in this way to postpone the fatal termination, 
and in a few instances has gained complete control over the disease. 

(Esophagus. — Carcinoma of the alimentary canal below the soft 
palate is composed of tissue derived from the hypoblast. The prevail- 
ing type of the epithelial cells of the tumor is the columnar. The 
pharynx is very seldom affected by carcinoma. The oesophagus, on 
the contrary, is quite frequently the seat of carcinoma. About half 
of the cases occur in the lower third, about one-third in the middle 
third, and the balance higher up. Mackenzie's observations led him 
to formulate different conclusions in reference to the part of the oesoph- 
agus most frequently affected. He based his statistics on 100 cases. 
Of these, 44 involved the upper third, 28 the middle third, and 22 the 
lower third. As Mackenzie was a throat specialist, it is to be expected 
that he was consulted more frequently by patients who suffered from 
carcinoma of the upper part of the oesophagus, which would explain 
the discrepancy existing between the statistics gathered by the general 
surgeon and those quoted by specialists in reference to the favorite seat 
of carcinoma of the oesophagus. All surgeons agree in the statement 
that cicatricial stenosis affects more frequently the upper, and carcinoma 
the lower, part of the oesophagus. 

Carcinoma of the oesophagus appears in two different pathological 
forms : (1) the soft variety, which leads to early ulceration and perfora- 
tion ; (2) the hard form, which results in the formation of a circular strict- 
ure. The circular stricture seldom involves more than an inch of the 
oesophageal tube. Not infrequently perforation into the trachea, the pos- 
terior mediastinum, or the pleura takes place. The writer saw in Von 
Ziemssen's clinic a case which was frequently presented before the class 
to demonstrate the existence of a communication between the oesoph- 
agus and the trachea. A few moments after the patient drank a few 
tablespoonfuls of milk he was attacked by a violent fit of coughing 
which did not cease until the milk he had swallowed was expectorated. 
The post-mortem showed a carcinoma of the oesophagus that had per- 
forated into the trachea. In some instances a fatal termination takes 
place from hemorrhage by perforation of the carcinoma into one of 



320 PATHOLOGY AND TREATMENT OF TUMORS. 

the large blood-vessels. In some cases the disease results in death 
without having produced any symptoms of obstruction. In the major- 
ity of cases, however, the first thing that attracts the patient's attention 
is that he is not able to swallow solid food. This difficulty gradually 
increases until only liquids can be swallowed, and finally the obstruction 
becomes complete. The food that is swallowed is not ejected imme- 
diately, a variable interval elapsing until the food is regurgitated. One 
of the results of the obstruction is a dilatation of the cesophagus above 
the stricture ; in cases of long-standing circular stricture the cesophagus 
becomes dilated into a large pouch holding a teacupful or more. The 
food is not vomited, but is regurgitated, and is ejected unchanged. As 
soon as the tumor interferes with deglutition marasmus very rapidly 
sets in, and death follows in a few weeks. Pain in the region of the 
tumor is slight or is entirely absent. 

In the differential diagnosis between cicatricial stenosis and carci- 
noma of the cesophagus it is necessary in the first place to inquire care- 
fully into the history of the case. Cicatricial stenosis usually develops 
after destruction of the mucous membrane by the swallowing of lye or 
of other caustic — an accident which occurs more frequently in children 
than in adults. Cicatricial stenosis occurs most frequently in children 
and young adults ; carcinoma of the cesophagus is seldom met with in 
persons less than fifty years of age. A gradually increasing stenosis 
of the cesophagus in persons advanced in life, in whom the clinical history 
does not reveal the existence of the usual causes of cicatricial stricture, is 
with very few exceptions indeed caused by a carcinoma. The existence 
of the obstruction must be demonstrated by the use of the olive-pointed 
oesophageal bougie. The largest size is to be used first to determine the 
seat, and then the smaller points to ascertain the extent, of the stricture. 
No force must be used in passing the instrument through the stricture. 
Disregard of this advice has repeatedly resulted in perforation of the 
cesophagus and death from immediate and remote complications caused 
by this accident. The writer has personal knowledge of two such cases : 
in one the perforation was followed by fatal hemorrhage, in the other 
by septic peritonitis. Dilatation of a carcinomatous stricture is contra- 
indicated, as it not only aggravates the local conditions, but is also 
attended by the risk of perforation. The use of elastic tubes is not 
attended by the danger of perforation, and if the stricture is permeable 
they are used to introduce into the stomach liquids and finely-divided 
food suspended in liquids. A small rubber tube inserted into the 
stomach from one of the nostrils can be retained and used for stomach- 
feeding. As soon as stomach-feeding is impossible even with the aid 
of elastic oesophageal tubes, a gastrostomy should be performed. This 



CARCINOMA. 



Plate 7. 





i. Witzel's method of performing gastrostomy. 2. Witzel's operation, showing tube buried by suture: 



CARCINOMA. 321 

operation should not be postponed too long. As a rule, patients are 
loath to accept this the last alternative to prolong their lives, and con- 
sequently frequently postpone the operation until it is too late. 

Gastrostomy . — Fenger's incision has been rendered obsolete by the 
many recent improved methods of establishing an external gastric fistula 
in cases of oesophageal obstruction. The operation that has found more 
favor with the profession than any other is Witzel's (PI. 7, Figs. 1, 2). 
One of the great difficulties to overcome in gastric feeding through an 
external fistula was the escape of food through the fistula after its intro- 
duction into the stomach. Witzel devised an operation that appears to 
answer all requirements better than any other. The abdomen is opened, 
under strict antiseptic precautions, through the left rectus muscle, a 
little to the left of the median line and a little below the tip of the 
xiphoid cartilage. The stomach is identified, and its anterior wall is 
brought well forward into the wound. A compress of gauze is packed 
around the projecting part of the stomach, and in its anterior wall there 
is made an opening large enough to insert a rubber tube a little larger 
than an ordinary lead pencil. The tube, about 6 inches in length, is 
then so inserted that its end projects well beyond the mucous surface 
of the stomach. There is then made in the anterior wall of the stomach 
a vertical groove deep enough to receive the rubber tube, when the 
serous surfaces are stitched together over and below the tube, so as 
to prevent the escape of fluid from the opening in the stomach into the 
peritoneal cavity. The tube is buried in this manner to the extent of 
two inches, when the stomach is fastened by stitches in the upper angle 
of the incision, and the balance of the wound is closed by suturing. 

Mikulicz modified Witzel's operation by stitching the anterior wall 
of the stomach around the sutures over the tube to each side of the 
external incision before closing the wound up to the fistulous opening. 
This should invariably be done, as it affords an additional safeguard 
against the escape of stomach-contents into the peritoneal cavity. 

If the patient is very much debilitated, stimulants and liquid food 
may be introduced at once into the stomach through the rubber tube. 
The distal end of the tube after feeding is either tied or compressed by 
a suitable clamp. The fistula established in this manner is oblique, and 
the internal opening is closed by a valve-like action of the upper part, 
which, even when the tube is removed, effectually prevents the escape 
of stomach-contents. Witzel recommends that after a few weeks the 
rubber tube be removed, and be inserted only when the patient feeds 
himself. The patient should masticate and insalivate the solid food 
before he pours or injects it into the stomach. The great mortality 
which has attended this operation so far is due to the fact that in the 
21 



322 PATHOLOGY AND TREATMENT OF TUMORS. 

majority of cases in which death resulted from the operation the patients 
had postponed it too long. If this operation is to prolong life, it must 
be performed in time, before the patient's strength has been reduced to 
the lowest ebb. 

Stomach. — Carcinoma of the stomach, which is by no means a 
rare affection, occurs most frequently in persons from thirty to sixty 
years of age. Sutton refers to a case in which the patient, a girl, was 
only thirteen years old. The youngest patient that has come under 
the writer's observation suffering from this disease was a man twenty- 
five years old. The pylorus is the part of the stomach most frequently 
implicated. Lebert found the disease here in 5 1 per cent, of the cases 
he examined, and Brinton, Gussenbauer, and Winiwarter have shown 
that the proportion of cases in which the pylorus is affected is still 
greater : they estimate it at 60 per cent. As all parts of the mucous 
membrane of the stomach are freely supplied with tubular glands, the 
histological structure of carcinoma of the stomach mimics tubular 
glands. Sections from new parts of the tumor show under the micro- 
scope a tubular structure (see Fig. 146). 

The character of the structure of the tumor is determined by the 
relative amount of epithelial cells to the stroma. If the parenchyma 
of the tumor largely preponderates over the stroma, the tumor grows 
rapidly, ulcerates early, and soon implicates the entire thickness of the 
wall of the stomach. These are the cases in which hemorrhage or per- 
foration frequently terminates life at an early stage. In the hard variety 
of carcinoma of the stomach, found most frequently at the pyloric end, 
the tissues become infiltrated slowly and to a limited extent. The 
circumference of the entire pylorus becomes implicated in the form of 
a ring-like, circular induration. The connective-tissue stroma contracts, 
and the lumen of the pylorus is progressively narrowed until finally it 
becomes impermeable to the passage of food from the stomach into 
the duodenum. In other cases the disease infiltrates the wall of the 
stomach very extensively, but no contraction of the stroma takes place. 
These are the cases in which during life, although the pylorus may 
show extensive disease, symptoms of obstruction do not occur. In 
carcinoma of the cardiac end of the stomach a circular carcinomatous 
stricture presents the same clinical evidences as carcinoma of the 
oesophagus, and requires the same treatment. In carcinoma of the 
stomach located between the cardiac and pyloric ends the symptoms 
are often very vague. Vomiting at irregular periods after meals, 
hematemesis, indigestion, progressive marasmus, and in some cases 
a palpable tumor, suggest the existence of a malignant tumor in this 
part of the stomach. Circular constricting carcinoma of the stomach 



CARCINOMA. 323 

gives rise to a clinical picture that is almost typical. Vomiting of 
unchanged or partly-digested food in from two to four hours after 
meals, attended by a sense of relief, gradual dilatation of the stomach, 
in advanced cases reaching as far as the pubes, and progressive emacia- 
tion, characterize the case. If the carcinoma appears in the form of 
a narrow constricting ring, it is often impossible to recognize the tumor 
by external palpation. If the tumor attains larger dimensions, it can 
be felt usually a little below the level of the normal pylorus, espe- 
cially after the stomach has been emptied of its contents by the use of 
the elastic stomach-tube. Hemorrhage is sometimes profuse, and even 
fatal if a large vessel, such as the pyloric branch of the hepatic artery, 
has been eroded by the carcinoma. In pyloric obstruction the retention 
of food leads to fermentation, which aggravates existing indigestion and 
ends in causing dilatation of the organ. 

The only disease which is likely to be mistaken for pyloric carci- 
noma is cicatricial stenosis of the pylorus. Cicatricial stenosis is the 
result of the healing of an antecedent ulcer in this locality, and the 
condition occurs, as a rule, in younger persons than does carcinoma. 
This form of obstruction is found more frequently in the female than 
in the male. The absence of a palpable tumor should not influence 

us in deciding in favor of the existence of a cicatricial stenosis, as fre- 
es ' 

quently no tumor can be detected externally in cases of circular con- 
stricting carcinoma of the pylorus. Free muriatic acid is frequently 
absent in carcinoma of the stomach, but this circumstance is no unfail- 
ing test for malignant disease, as this acid may be absent in obstruction 
caused by non-malignant disease, and may be present during the early 
stage of carcinoma. The occurrence of vomiting in from one to three 
hours after meals in persons more than fifty years of age should excite 
suspicion of carcinoma. If the vomited material is mixed with 
grumous blood, presenting the appearance of coffee-grounds, if the 
vomiting is followed by a sense of great relief, and if the symptoms 
do not yield within a short time to the usual treatment, it is very proba- 
ble that the patient is suffering from carcinoma of the stomach, although 
no palpable tumor may be present. 

Inflation of the stomach after evacuating the organ by the use of 
the stomach-tube is the most reliable and safest way by which to deter- 
mine the presence and extent of dilatation. The area of tympanites 
will at least approximately correspond with the size of the stomach. 
If the large curvature of the stomach reaches the umbilicus, the organ 
has become dilated. During the examination for a tumor of the 
stomach the patient should be placed in the dorsal recumbent position 
with the chest elevated and the legs and thighs flexed. Succussion 



324 PATHOLOGY AND TREATMENT OF TUMORS. 

after the introduction of a small quantity of fluid into the stomach 
suggests very strongly the existence of dilatation (Bouchard). 

Carcinoma of the stomach, with few exceptions, proves fatal within 
a year. Perforation into adjacent viscera, duodenum, and transverse 
colon may prolong life by creating a new outlet for the stomach-con- 
tents into the intestinal canal. If perforation into the free peritoneal 
cavity takes place, death from peritonitis usually ensues. Death from 
recurring hemorrhages follows the erosion of an artery of considerable 
size. In most instances of carcinoma of the pylorus the immediate 
cause of death is inanition resulting from the suspension of digestion 
caused by mechanical obstruction. 

Metastasis occurs in connection with carcinoma of the stomach. 
When the carcinoma reaches and involves the peritoneal coat of the 
stomach, regional dissemination often takes place by the dispersion of 
carcinoma-cells or fragments of tissue over the adjacent serous surfaces. 
In this way the great omentum often becomes extensively infected. 
The lymphatic glands in the gastro-hepatic omentum are infected in 
more than two-thirds of the cases. The lumbar, cervical, and medias- 
tinal lymphatic glands are occasionally the seat of regional infection. 

Treatment. — Careful attention to the diet and the use of the siphon 
stomach-tube in the cases in which dilatation from pyloric obstruction 
has taken place are to be relied upon in the conservative treatment of 
carcinoma of the stomach. The internal administration of salol and 
bismuth affords relief when the obstruction has given rise to catarrhal 
inflammation of the gastric mucous membrane. The observation that 
carcinoma of the pyloric orifice of the stomach is frequently very limited 
in extent, and that patients succumb not so much to the malignant dis- 
ease as to the effects caused by the mechanical obstruction, has induced 
surgeons to desist from operations for the removal of the carcinomatous 
pylorus. 

Pylorectomy : — The first experimental pylorectomies on dogs were 
made in 1810 by Merem. Parts of the stomach were removed for 
other indications than carcinoma by Torelli and Esmarch. Accurate 
experimental investigations concerning the feasibility of pylorectomy 
for carcinoma were made by Gussenbauer, Winiwarter, and Kaiser. 
The pylorus was removed for the first time for disease by Pean., 
Billroth made the first successful pylorectomy. The success of the 
operation has not been what was expected from it. In 66 cases death 
occurred soon after the operation in 50. Only in a few cases was life 
prolonged for any considerable length of time. One of Wolfler's cases 
lived three and a half years after the operation. That the operation has 
not yielded better results is due to the fact that the local extension of 



CARCINOMA. 



325 



the tumor and the regional infection were such as to require very exten- 
sive operations, to the immediate effects of which many of the patients 
succumbed ; and for the same reasons, in those that survived the imme- 
diate effects of the operation the disease returned soon afterward. In 
the fifteen cases of abdominal section made by the writer for carcinoma 
of the stomach the disease was found too extensive and regional infec- 
tion too diffuse to warrant pylorectomy in all the cases but one, and in 
this one the circular carcinomatous stricture of the pylorus had resulted 
in such great impairment of the strength of the patient as to preclude 
the advisability of resorting to a pylorectomy. 

Surgeons have gone too far in the radical treatment of carcinoma 
of the pylorus. In the writer's estimation the operation is warranted 
only if the disease remains limited to the organ primarily affected, and 
if the patient is strong enough to resist the immediate effects of the 
operation. The stomach is washed out immediately before the opera- 
tion. If the organ is thoroughly emptied before the operation, there is 
hardly any need for the different mechanical devices (Fig. 202, a, b, c, d) 




VI 

\1 " 




Fig. 202.— Intestinal and stomach clamps : a, after Rydygier ; b, after Billroth ; c, after Hahn ; d, aftei 

Heineke. 

which have been employed for the purpose of preventing the escape 
of duodenal and stomach-contents. Catch-forceps of special construc- 
tion (Figs. 203, 204) have also been employed for the same purpose 
For the prevention of the escape of intestinal contents nothing equals 
in efficiency and ease of application the elastic constrictor. A small 
rubber tube about a foot in length is drawn through a buttonhole made 



326 



PATHOLOGY AND TREATMENT OF TUMORS. 



with a pair of hemostatic forceps in the mesentery near its attachment 
to the bowel. This tube is tied with sufficient firmness to prevent the 
escape of intestinal contents. It is not in the way of the operator, and 
it is less likely to inflict unintentional injury to the bowel or the adjacent 





Fig. 203. — Intestinal forceps (after Gussenbauer). 



Fig. 204. — Intestinal forceps (after Kiister). 



parts than the different kinds of clamps or forceps. Sterilized gauze 
should be packed around and on the sides of the part to be resected, 
to absorb any fluid that might escape during the operation. 





Fig. 205. — Resection of the pylorus after Billroth-Wolfler: I, location and direction of visceral incisions; 
2, suturing: a, occlusion-sutures ; b, circular sutures. 

The abdomen is usually opened in the median line, below the tip 
of the xiphoid cartilage, far enough to secure free access to the pylorus. 
Billroth prefers an oblique incision below and parallel to the right 
costal arch. The mesenteric attachment of the part to be resected 



CARCINOMA. 



327 



should be tied in small sections with fine braided silk. The lumen of 
the stomach is made to correspond with the oblique section of the 
duodenum by closing a part by Czerny-Lembert sutures before it is 
joined with the duodenum. The junction between duodenum and 
stomach is made with the same kind of sutures. The suturing is done 
in steps as the excision wound is enlarged. This method affords a 
better opportunity to coaptate the parts properly, and is attended by 
less hemorrhage, than if the excision were made at once. 

Rydygier diminishes the size of the opening in the stomach from 
the larger instead of from the smaller curvature of the stomach (Fig. 





KlG. 206. — Resection of the pylorus (after Rydygier) : a, location and direction of incisions ; b, sutures. 

206, b). Canalization difficulties are less likely to follow the operation 
if the duodenum is united with the greater curvature of the stomach 
according to the Billroth-Wolfler op- 
eration than when it is attached to 
the lesser curvature, as recommended 
by Rydygier. The difficulties expe- 
rienced in uniting the duodenum with 
the stomach when a large part of this 
organ has to be removed have led 
Billroth to combine pylorectomy with 
gastro-enterostomy in the operative 
removal of large carcinomatous tu- 
mors of the pyloric portion of the 
stomach (Fig. 207). The resected 
ends of the stomach and duodenum 
are closed by a double row of su- 
tures, and a communication is established between the anterior wall 
of the stomach and the lower part of the duodenum or the upper part 
of the jejunum by making in each of these organs a longitudinal slit 
at least two inches in length and uniting them by Czerny-Lembert 
sutures. Tuholsky of St. Louis is an ardent advocate of this operation, 
but he advises that it should be done a deux temps. 




Fig. 207. — Resection of the pylorus with gastro- 
enterostomy (after Billroth). 



328 PATHOLOGY AND TREATMENT OF TUMORS. 

Gastroenterostomy . — The limited success of pylorectomy induced 
Wolfler to devise an operation for the relief of patients suffering from 
pyloric carcinoma too far advanced for a radical operation. This opera- 
tion is called gastro-enterostomy, and consists in establishing between 
the stomach and the upper part of the intestinal canal a communica- 
tion, thus excluding permanently from the gastro-intestinal canal the 
affected part. The stomach is prepared for the operation in the same 
manner as for pylorectomy. It is advisable to wash out the stomach 
daily at least for two days before the operation, and to nourish the 
patient during this time exclusively by rectal feeding. The intestinal 
canal should be cleared of its contents by a mild laxative or a high 
rectal enema. In one instance the writer performed this operation 
without an anesthetic. The only pain which the patient complained of 
was produced by making the external incision. The handling of the 
stomach and the intestines, the visceral incisions, and the suturing 
appeared to cause little or no pain. 

If no contraindications exist, chloroform should be used in perform- 
ing this as well as other operations on the gastro-intestinal canal, in 
preference to ether, as the use of chloroform is attended and followed 
by less retching and vomiting than is the case when ether is used. 
The abdomen is opened by a straight incision in the median line ex- 
tending from the xiphoid cartilage to the umbilicus. The upper part 
of the intestinal tract, at a point about twelve inches below the pyloric 
orifice of the stomach, is brought forward into the wound with the 
anterior wall of the stomach. 





Fig. 208. — Formation of valve to prevent entrance of Fig. 209. — Implantation of duodenum into jejunum 
stomach-contents into duodenum (after Wolfler). and jejunum into stomach (after Wolfler). 

Gastro-enterostomy after Wolfler. — Wolfler intended to prevent the 
entrance of bile into the stomach, and of stomach-contents into the 
duodenum, by forming a valve by uniting the right half of the opening 
in the bowel with the intact stomach-wall, and only the left half with 
the margin of the opening in the stomach (Fig. 208). The same object 



CARCINOMA. 



329 




Fig. 210. — Gastro-enterostomy (after Liicke). 



is attained if the bowel is completely divided at the junction of the 
duodenum with the jejunum, and the proximal end is implanted into 
the jejunum and the jejunum into an 
opening in the anterior wall of the stom- 
ach, as shown in Figure 209. Liicke 
reversed the position of the bowel as 
recommended by Rockwitz, in order to 
bring the peristaltic action of the intes- 
tine in accord with the movements of 
the stomach (Fig. 210). 

In making the communication be- 
tween the stomach and the intestines 
large enough, some allowance must be 
made for cicatricial contraction of the 
opening. The visceral incision should be at least two inches in length. 
The stomach and the bowel should be united behind by sero-muscular 
sutures before the visceral incisions are made, as recommended by 
Lauenstein. After the incisions have been made the deep sutures are 
applied all around, when the incision is completed by a row of super- 
ficial sutures in front and on the sides. 

Gastro-enterostomy after Senn. — The writer has made fifteen gastro- 
enterostomies by substituting in part for the sutures plates of decal- 
cified bone with a central perforation at least two inches in length and 
three-quarters of an inch wide. The intestine is brought into the 
Rockwitz position and is united with the stomach behind by a row of 
sero-muscular sutures. An incision two inches 
in length is made in the stomach and the duo- 
denum ; the plates are then inserted, and are 
brought into proper position by making trac- 
tion on the fixation-sutures ; the lateral sutures, 
armed with needles, are now passed through 
all the tissues except the peritoneum, and 
the terminal sutures are brought out at the 
angles of the visceral wounds. An assistant 
coaptates the wounds, and the lower fixation- 




suture is tied with sufficient firmness to bring 



FiG. 2ii. — Moist perforated decal- 
cified bone-plate. 



the parts in apposition without endangering 
their blood-supply by strangulation ; next the terminal sutures are tied, 
and finally the superficial fixation-sutures. Before tying the last suture 
the margins of the wound must be carefully brought well between the 
plates to prevent eversion. All the sutures are cut close to the knot. 
The union is completed by stitching the serous surfaces over the 



33© PATHOLOGY AND TREATMENT OF TUMORS. 

anterior margins of the plates, thus completing the ring of superficial 
sutures (Fig. 212). 

The results following the use of the bone plates in performing 
gastro-enterostomy for carcinoma have been most encouraging. The 



Ensiform process 



Ascending colon 




Jejunum. 



Fig. 212. — Method of performing gastro-enten>stomy (illustration after Von Baracz). 

union between the parts interposed between the plates can be hastened 
by free scarification. Since using plates with a perforation at least two 
inches in length the writer has seen no ill results from cicatricial con- 
traction. In one case of pyloric carcinoma in a man thirty years of 
age, the patient, who was brought to the hospital on a stretcher, ema- 
ciated to a skeleton, gained sixty-five pounds in weight after operation, 
resumed his occupation, that of a butcher, worked for a year and 
a half, and then gradually sunk from the effects of the carcinoma. In 
another case, that of a man seventy years of age, emaciated to an 
extreme degree, the patient recovered sufficient strength to conduct 
his business for over a year after the operation. In a number of 



CARCINOMA. 



33 1 



instances the patients lived for three, four, and eight months in comfort 
and ease — a sufficient recompense for the risk assumed in subjecting 
themselves to a gastroenterostomy. In the majority of cases of 
pyloric carcinoma the surgeon will have to content himself with making 
a gastroenterostomy until by improved diagnostic resources we will 
be able to recognize carcinoma of the stomach early enough to warrant 
a more frequent recourse to a radical operation by pylorectomy or by 
partial gastrectomy. 

Intestines. — Carcinoma is more frequent in the lower than in the 
upper part of the intestines. Of every ioo cases, 75 occur in the rec- 
tum ; of the remainder, 23 would be localized in the large bowel and 
2 in the small intestine, including the ilio-cecal valve, and would prob- 
ably be distributed in the following manner : Small intestine and ilio- 
cecal valve, 2 ; cecum, 2 ; hepatic flexure of colon, 3 ; splenic flexure 
of colon, 4 ; sigmoid flexure, 10 ; intermediate segments of colon, 4 
(Sutton). Carcinoma of the intestines represents in its minute struct- 
ure the glandular appendages of the mucous membrane lining the 
intestinal canal (Fig. 213). The irregular tubules are lined with cylin- 




Fig. 213.— Cylindrical-celled carcinoma of the intestine; X 128 (after Hauser) : above, elongated and 
distended granular spaces ; below, without a sharp border, these tubules terminate in irregular carcinoma- 
alveoli. The black points indicate cells undergoing karyokinesis. 

drical cells. In the periphery of the tumor the cells which have parted 
from the parent soil and have escaped through the imperfect membrana 



332 PATHOLOGY AND TREATMENT OF TUMORS. 

propria infiltrate the surrounding connective-tissue spaces, and the new 
cells which they produce arrange themselves again in tubular shape, 
the pre-existing connective tissue becoming the stroma of that part 










Fig. 214. — Periphery of cylindrical-celled carcinoma of the cecum; X no (Surgical Clinic, Rush 
Medical College, Chicago) : a, rows of carcinoma-cells in connective-tissue spaces ; b, intervening con- 
nective tissue. 

of the tumor. The section represented in Figure 214 was taken from 
the periphery of a circular constricting carcinoma of the cecum. The 
tumor had produced intestinal obstruction. 

The parenchyma and the stroma of intestinal carcinoma are very 
apt to undergo colloid degeneration. Regional and metastatic infection 
occurs earlier and more constantly than in squamous-celled carcinoma. 
Carcinoma of the intestines is seldom recognized, or even suspected, 
before the tumor has produced symptoms of obstruction. Chronic 
obstruction from this cause is frequently attended by diarrhea, a symp- 
tom which frequently leads patient and physician into errors in diag- 
nosis. 

Acute obstruction is caused either by the affected segment of the 
intestine becoming invaginated or by a suddenly-developed paretic con- 
dition of the bowel above the seat of obstruction. Great hypertrophy 
of the muscular coat of the bowel above the obstruction is usually 
associated with chronic obstruction, and an acute attack is initiated 
when compensatory hypertrophy no longer keeps pace with the increas- 
ing mechanical impediment or when the narrowed part of the bowel 
becomes impermeable by impaction of some foreign substance or of a 
hardened fecal mass. In cases of acute intestinal obstruction in per- 
sons advanced in years the existence of a malignant intestinal tumor 
should be borne in mind. As in the pylorus, carcinoma of the intestine 
occurs either as a diffuse tumor attaining considerable size or as a cir- 
cular constriction. The former variety is more liable to ulceration and 



CARCINOMA. 



333 



perforation ; the latter gives rise to intestinal obstruction. In the con- 
stricting variety the tumor involves the entire circumference of the 
bowel, and by constriction of its 
stroma the lumen of the bowel is 
gradually reduced in size (Fig. 
215). The bowel on the distal 
side becomes much smaller in 
size, while on the opposite side 
of the constriction it becomes 
distended and all its coats are 
hypertrophied to some distance 
from the seat of obstruction. 
The catarrhal inflammation 
caused by the accumulation of 
feces and the greatly increased 
peristaltic action cause the fre- 
quent liquid discharges, which 
are taken only too often by the 
superficial observer as an indi- 
cation of the absence of a me- 
chanical obstruction. Chronic 
intestinal obstruction caused by a 
carcinoma is attended by inter- 
mittent paroxysmal pain which 
is referred to the region of the 
umbilicus, irrespective of the an- 
atomical location of the tumor. 

Operative Treatment. — Unless the tumor has given rise to a palpable 
swelling, the surgeon has seldom an opportunity to perform a radical 
operation until symptoms of chronic or acute intestinal obstruction 
set in. In making a laparotomy for intestinal obstruction the surgeon 
must be prepared to meet with such a condition. A radical operation 
is indicated if the carcinoma has not passed beyond the limits of the 
bowel and the patient's strength is adequate to resist the immediate 
effects of an enterectomy. If the patient has become prostrated from 
the effects of the intestinal obstruction, it is advisable to resort to the 
formation of an artificial anus above the obstruction, and to postpone 
the operation until his strength has been recuperated sufficiently. 

Enterostomy. — If the tumor occupies the ilio-cecal region, a tem- 
porary artificial anus is established in the right inguinal region by 
bringing into the wound the first distended knuckle of the small intes- 
tine that presents itself. The intestine is united with the peritoneum 




Fig. 215. — Cancer of the colon — constricting variety 
(after Sutton). 



334 



PATHOLOGY AND TREATMENT OF TUMORS. 



of the external incision, and the bowel is opened by a transverse 
incision about an inch in length. If the carcinoma is located below 
the sigmoid flexure, a sigmoidostomy in the left groin is made. These 
operations are indicated in cases in which the obstruction is acute and 
the patient's general condition does not permit of an operation requiring 
more time. 

Entcrectomy. — The removal of a malignant tumor of the intestine 
requires an enterectomy. The removal of a limited segment of the 
bowel for malignant disease, if the patient's strength has not been too 
much exhausted and no regional infection has occurred, is a legitimate 
procedure, and is often followed by a permanent cure. The operation 
should not be undertaken if extensive malignant adhesions have formed 
or if the lymphatic glands have become extensively infected. The 
bowel on each side of the tumor should be constricted with a piece of 
rubber tubing passed through an opening made in the mesentery near 
its attachment to the bowel (Fig. 216). Before the incisions through 





filBm 




Fig. 216. — Separation of mesentery from bowel (after 
Kocher). 



Fig. 217. — Circular suture and folding of mesen- 
tery after enterectomy (after Kocher). 



the bowel are made the mesentery should be tied in small sections with 
fine silk. The bowel sections are made somewhat obliquely at the 
expense of the convex side, and the ends are at once united with a 
double row of sutures. The mesentery corresponding with the section 
of bowel removed should not be excised, but be folded upon itself, and 
the ligatured margin should be sutured as shown in Figure 217. If 
the lumina of the bowel-ends do not correspond in size, the smaller end 
is cut more obliquely. If the difference in size is too great, to be equal- 
ized by this method, as after excision of the cecum, both ends are 
closed, and the continuity of the bowel is restored by lateral anasto- 
mosis, by suturing, or with the aid of perforated decalcified bone-plates. 
The use of decalcified perforated bone-plates to restore the continuity 
of the bowel has been resorted to by the writer in three cases of resec- 



CARCINOMA. 



335 



tion of the cecum for carcinoma, and in every instance this method 
of approximation proved eminently successful (Fig. 218). 





Fig. 218. — Restoration of the continuity of the bowel after resection of the cecum for carcinoma, with the 
aid of perforated decalcified bone-plates. 

Intestinal Anastomosis. — If the carcinoma, by the promotion of car- 
cinomatous adhesions with neighboring organs or by extensive regional 
infection through the lymphatic channels, has advanced beyond the 
limits of a radical operation, an intestinal anastomosis should be made. 
This operation consists in establishing a fistula between the bowel 
above and below the tumor. 

A R 

The operation can be done 
by making in the respective 
parts of the bowel an incis- 
ion four inches in length, 
as advised by Abbe, and 
the union is effected by a 
double row of silk sutures. 
A single row of sutures 
might prove all-sufficient, 
but as a matter of safety a 
double row is preferable. 




The same object can be 
accomplished in a shorter 



time and with a greater de- 



Fig. 219. — Intestinal anastomosis with the aid of perforated 
decalcified bone-plates in the operative treatment of inoperable 
carcinoma of the bowel (after Esmarch) : A, plates in situ ; 
b, operation completed. 

gree of security by substi- 
tuting for the inner row of sutures perforated decalcified bone-plates 
(Fig. 219). The anastomotic opening should correspond in size with 
the lumen of the bowel. 

The use of the Murphy button would be attended by great danger 



33 6 



PATHOLOGY AND TREATMENT OF TUMORS. 



in such cases, as the button would be just as likely to fall into the blind 
end of the bowel on the proximal side of the obstruction as into the 
opposite side. Besides, it has been shown by Keen and others that 
the opening, small in the beginning, is apt to become contracted beyond 
the limits of its requirements in a comparatively short time. 

Rectum. — Carcinoma of the rectum occurs more frequently than 
carcinoma of the remaining portion of the intestinal canal, its greater 
frequency here being probably accounted for by the rectum being 
more often the seat of benign growths, of chronic inflammatory affec- 
tions, and of prolonged irritations from different sources. The histo- 
logical structure of most of the rectal carcinomata presents a tubular 




Fig. 22o.-Cylindrical-celled carcinoma of the rectum ; X 480 (Surgical Clinic, Rush Medical College, Chicago) : 
a, connective-tissue stroma ; i, atypical tubules of carcinoma ; c, cylindrical epithelial cells. 

arrangement of the cells, surrounded and enclosed by a connective-tissue 
stroma which in the soft variety of tumors is exceedingly scanty, and 
in the hard, constricting variety is veiy abundant and compact (Fig. 
220). In the rapidly infiltrating form the rectal tube becomes indurated 
and the surface ulcerates, but its lumen is not much reduced in size. 
In the circular constricting form the constricting ring is very dense and 
the lumen of the bowel is rapidly diminished in size. This is the form 



CARCINOMA. 337 

of rectal carcinoma that produces obstruction and is most favorable to 
operative treatment, owing to the limited extent of the tumor and the 
dilated condition of the bowel above the obstruction, permitting the 
bowel to be drawn down after removal of the carcinomatous part. 

The writer has already referred to a case that came under his obser- 
vation of carcinoma of the rectum in a boy eighteen years of age. Car- 
cinoma of the rectum, however, with few exceptions is a disease of 
advanced life. According to Hildebrandt's statistics, 16 per cent, of 
rectal carcinomata occur in persons less than forty years old, 54 per 
cent, in persons forty to sixty years of age, and 30 per cent, in persons 
from sixty to eighty years old. The carcinoma is located most fre- 
quently in the lower third of the rectum. The stagnation of feces 
aggravates the ulcerative process and produces at the same time a 
catarrhal proctitis above the tumor. Local extension takes place in 
the direction of the connective tissue outside of the rectum, in advanced 
cases rendering the rectum as immovable as though it were held in 
a vise. Regional infection takes place in the rapid-growing variety 
at an early stage, and extends in the direction of the chain of sacral 
and lumbar lymphatic glands. In advanced cases the regional infec- 
tion occasionally includes the inguinal glands. Metastasis of different 
organs hastens the fatal termination. The statement has already been 
made that cylindrical carcinoma gives rise earlier and more constantly 
to metastasis than does carcinoma representing epiblastic tissue. 

Symptoms and Diagnosis. — Carcinoma of the rectum is not attended 
by much suffering until the tumor by its size or by constriction gives 
rise to obstruction. A sense of weight and an aching feeling in the 
sacral region, usually attributed to rheumatism or hemorrhoids, is 
about all the patient complains of during the early stages. The dis- 
charge of a little blood and mucus, and constipation alternated by 
diarrhea, are the symptoms which usually induce the patient to seek 
medical advice under the belief that he is suffering from piles. Patients 
giving such a clinical history should always be subjected to a thorough 
rectal examination. Digital exploration is more to be relied upon in 
conducting this examination than the use of the different kinds of rectal 
specula. The patient should be brought into the exaggerated lithotomy 
position. With the right index finger well lubricated the rectum is 
explored, and unless the carcinoma involves the first part of the rectum 
the tumor is discovered without any difficulty. In the constricting 
variety the lower end of the tumor with the constricted lumen feels 
very much like an enlarged lacerated cervix uteri. The size of the 
lumen and the mobility of the affected part are now determined, after 
which careful search should be made for enlarged lymphatic glands in 



338 



PATHOLOGY AND TREATMENT OF TUMORS. 



the sacral fossa. If the tumor has infiltrated the rectal wall without 
having produced contraction, the rectum feels like a firm, unyielding 
cylinder with points of ulceration of its mucous lining. 

In cicatricial stenosis of the rectum, the only condition liable to be 
mistaken for carcinoma, the stricture is usually near the anus, infiltra- 
tion of the rectal wall is less marked, any considerable enlargement of 
the sacral glands is absent, and the stricture is often multiple, which 
latter is not the case in carcinoma. Should any doubt exist as to the 
differential diagnosis between these two rectal affections, a fragment of 
tumor-tissue should be removed and sections of it be examined under 
the microscope. 

Indications for a radical operation are absence of paraproctitic infil- 
tration and of extensive lymphatic infection, and a sufficient accessibility 
of the tumor to enable the surgeon to remove all the diseased tissue 
by a radical operation. Opposite conditions must be regarded as posi- 
tive contraindications to any radical measures. 

Palliative Operations. — In inoperable cases of carcinoma of the rec- 
tum the surgeon can do a great deal to alleviate the suffering of the 
patient by establishing an artificial anus in the left inguinal region. 
Removal of the carcinomatous tissue projecting into the lumen of 
the bowel by scraping, and linear rectotomy, for the purpose of ame- 
liorating the symptoms due to 
obstruction, have become, for 
substantial reasons, obsolete 
measures. If the carcinoma 
produces obstruction, an arti- 
ficial anus will benefit the 
patient in two ways : it will 
exclude from the fecal circula- 
tion the diseased part of the 
rectum, and at the same time 
will establish a free outlet for 
the intestinal contents. If an 
artificial anus is made under 
such circumstances, it should 
be made with a view of com- 
pletely interrupting the fecal 
circulation and thus affording 
absolute rest for the excluded 
part of the bowel. Maydl's colostomy (Fig. 221) will answer these 
requirements to perfection. An incision four inches in length is made 
about two inches above Poupart's ligament, halfway between the symphy- 




Fig. 221. — Maydl's inguinal colostomy. 



CARCINOMA. 



339 




sis pubis and the anterior superior spinous process of the ilium, parallel 
with the fibres of the external oblique muscle. The muscular layers are 
separated as far as possible by the use of blunt instruments. The trans- 
versalis fascia and the peritoneum are incised to the extent of the external 
wound. Some care is now necessary to recognize, seize, and bring for- 
ward into the wound in proper position the sigmoid flexure. As soon 
as the proper loop has been found the mesentery near the bowel is tun- 
nelled with a hemostatic forceps, and a glass tube four 
inches in length, the size of an ordinary lead pencil, 
covered by several layers of gauze, is drawn through 
this opening with the forceps. The glass tube serves 
as a bridge for the prolapsed loop of the bowel. 
The two limbs of the bowel are now sutured tog-ether 

° Fig. 222.— Maydl's co- 

on each side by two sero-muscular sutures under- lostomy, showing the posi- 
neath the bridge (Fig. 222). Next, the prolapsed ,ion of the bridge u and the 

° x ° 7 1 L sutures underneath it. 

loop is sutured at its base to the parietal peritoneum 
by at least six points of suture, to prevent the escape of intestinal 
loops. If the symptoms are urgent, the base of the loop is surrounded 
by a ring of absorbent cotton fastened to the bowel and the skin by 
collodion ; the bowel is then, at the most prominent part, divided trans- 
versely to the extent of at least two inches. If the symptoms are not 
urgent, it is much safer to postpone the opening of the bowel for two 
or three days, until the peritoneal cavity has become shut out by 
adhesions all around. If this course is adopted, an ordinary antiseptic 
dressing is applied, taking the precaution that the intestinal loop should 
not be subjected to harmful pressure. On the second or third day the 
dressing is removed, the collodion ring is applied, and the bowel is 
incised as indicated above. It is advisable to keep the bridge in place 
for at least a week or two, in order to secure at a point opposite to it 
the formation of an efficient spur. Complete section of the bowel at 
this time is recommended by some ; but it is not necessary, as the spur, 
if well developed, will direct all the intestinal contents away from the 
lower part of the bowel, and the bowel on the distal side can be flushed 
from time to time as may appear necessary. 

Extirpation of the Rectum for Carcinoma. — Extirpation of the carci- 
nomatous rectum is now generally made through the sacral route. A 
long time ago, Kocher recommended removal of the coccyx as a pre- 
liminary step to the removal of the lower part of the rectum. Encour- 
aged by the success attending the removal of the rectum from this 
direction, surgeons have become bolder and have sacrificed parts of 
the sacrum for the purpose of securing better access to the diseased 
rectum. The resection, temporary or permanent, of a part of the pos- 



34° 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 223. — Resection of sacrum in extirpation of 
rectum for carcinoma: a, after Kraske; a-a', after 
Bardenheuer ; b, after Volkmann, Rose. 



terior bony wall of the pelvis has enabled surgeons to extend the field 
of radical operations upon the rectum for malignant disease. 

The different points where the sacrum has been divided in the ope- 
ration for extirpation of the rectum are shown in Figure 223. 

As is the case with similar operations in other parts of the body, 

the application of the principle of 
sacral resection as a preliminary 
step to extirpation of the rectum 
has been carried too far. It appears 
to the writer unjustifiable to carry 
the resection of the sacrum as far 
as has been done by Volkmann and 
Rose. The simple removal of the 
coccyx will often suffice in afford- 
ing ample room for the removal of 
the lower part of the rectum, and 
Kraske's operation will usually ac- 
complish all that could be desired 
in the removal of a carcinomatous 
rectum when the disease is within the limits of a justifiable operation. 

The patient should be prepared for a number of days for the opera- 
tion by dieting, laxatives, warm baths, and colonic irrigation, so as to 
secure for the part, as nearly as can be done, an aseptic condition. 
Immediately before the operation the lower part of the rectum should 
be flushed thoroughly with Thiersch's solution, and the external sur- 
face should be scrubbed thoroughly with warm water and potash soap, 
and later be disinfected with a solution of corrosive sublimate or of 
carbolic acid. After the patient is under the influence of an anesthetic 
he is placed face down upon a low table or a cot, the pelvis is elevated 
by placing under it pillows covered by rubber sheeting, and the thighs 
and the legs are flexed. This position diminishes the amount of venous 
hemorrhage, and the abdominal organs gravitate toward the chest, 
leaving the pelvis comparatively empty. An incision is then made in 
the median line from the centre of the sacrum to the verge of the anus. 
The coccyx is enucleated, and the lower two sacral vertebras are isolated 
from the soft tissues by the use of the knife and the periosteal elevator.. 
The sacrum is then divided transversely between the last two foramina 
with a large chisel and a mallet. All hemorrhage is then carefully 
arrested. After this step of the operation minute details as to the 
immediate arrest of hemorrhage by the use of hemostatic forceps must 
be carried out. By careful dissection between tissue-forceps the rectum 
is reached. As soon as this has been done cutting instruments should. 



CARCINOMA. 341 

be used sparingly. The rectum should be enucleated rather than 
excised. Connective-tissue bands and muscles are isolated before they 
are cut. The proximal end of the tumor should be reached first. If 
the rectum has to be removed high up, the peritoneal cavity is opened 
carefully, and prolapse of intestines, as well as the entrance of blood 
into the peritoneal cavity, is prevented by packing the opening with 
gauze sponges well secured in a hemostatic forceps. When healthy 
tissue is reached, a strip of gauze is tied around the rectum sufficiently 
tight to prevent escape of intestinal contents, after which the bowel is 
divided below transversely. The bowel is then drawn downward, 
and the diseased segment is separated by a careful dissection. If pos- 
sible, the external sphincter muscle is preserved. The course to be 
pursued now depends on how far the rectum has to be removed in a 
downward direction. If the distal end can be preserved, the surgeon 
can select one of two procedures. The proximal end can be united 
with the distal end by circular enterorrhaphy. Owing to the absence 
of a peritoneal investment in the lower end, this procedure has not 
yielded good results. Hochenegg has suggested that the proximal 
end should be invaginated into the distal end and be sutured to a cir- 
cular denudation at the anus. The results after this procedure have 
been more satisfactory than those after the first-named method. If the 
lower part of the bowel has to be removed, the resected end is drawn 
downward and is attached to the external skin by sutures. The bowel 
end must be ruffled so as to diminish its lumen before it is attached : 
this can be done with a circular purse-string suture of catgut. In 
either of these procedures the cavity of the wound is packed with 
iodoform gauze, over which the external wound is sutured except at 
from one to three places, where the gauze is brought out to the sur- 
face. The patient should be given a liquid diet for a few days, and 
small doses of opium to constipate the bowels temporarily. If no con- 
traindications arise, the gauze should remain for at least a week. At 
this time the whole wound-surface is covered by a pavement of active 
granulations that will guard against infection later. The wound pre- 
senting such a condition heals in a remarkably short time. 

If the rectum is amputated high up and the resected end cannot be 
brought down, a sacral anus is established by suturing the bowel into 
the upper angle of the external incision. The writer has pursued this 
course a number of times, and believes that an artificial anus in this 
locality has a number of advantages not possessed by an artificial anus 
devoid of a proper sphincter muscle lower down. Should the wound 
suppurate, enough sutures are removed to secure free drainage. In 
this event the dry dressing must give way to frequent antiseptic irriga- 



342 



PATHOLOGY AND TREATMENT OF TUMORS. 



tions and to a compress of gauze kept moist with a saturated solution 
of acetate of aluminum or of boric acid. 

If the carcinoma returns, little is to be expected from another ope- 
ration, as the local recurrence is usually accompanied by extensive 
infiltration and lymphatic infection. The formation of an artificial anus 
in such cases is never indicated, as the recurring carcinoma does not 
constrict the bowel, but extends to the pelvic connective tissue. 

Testicle. — Carcinoma as compared with sarcoma of the testicle is 
an exceedingly rare affection. Sometimes it engrafts itself upon the 
basis of an antecedent benign tumor or an inflammatory affection. The 







Fig. 224.— Carcinoma and tuberculosis of the testicle; X 85 (Surgical Clinic, Rush Medical College, 
Chicago) : a, stroma of carcinoma; b, alveolus packed with carcinoma-cells; c, focus of caseous degenera- 
tion; d, miliary tubercles in carcinoma-tissue. 



section from which the illustration (Fig. 224) was taken was derived 
from a testicle that had been tubercular for a long time and had only 
recently commenced to increase rapidly in size. This specimen refutes 
the assertion made by Rokitansky, that tuberculosis and carcinoma 
exclude each other. There can be no doubt in this case that the tuber- 
cular epididymitis was the primary and carcinoma the secondary affec- 
tion. Sutton has never seen a tubn^^^^uttia °fj]e testicle. That 



CARCINOMA. 



343 



such a carcinoma occasionally, although rarely, occurs is shown by 
Figure 225. Langhans never saw hard, but always soft, carcinomata 
of this organ. He believes that the tumor starts from the epithelial 
cells lining the seminiferous tubules. He also calls attention to the 
transformation of an adenoma of the testicle into a carcinoma. 

From a diagnostic point of view it is important to remember that 
tuberculosis almost always begins in the epididymis, and carcinoma in 




Fig. 225. — Tubular carcinoma of the testicle ; X 270 (after Karg and Schmorl). The tumor is composed 
of long, solid streaks of large epithelial cells (a). The nuclear structures cannot be seen, as the chromatin 
has been affected by the hardening solution, Muller's fluid. The stroma (£>) is scanty and is rich in cells. 

the testicle proper. As carcinoma of this organ is always soft, it is 
liable to undergo cystic degeneration — an occurrence which still further 
complicates the diagnosis. The regional infection extends along the 
lymphatics of the cord and from the cord to the iliac fossa. The tumor 
may attain the size of an adult's head. 

Early removal of the testicle with its envelopes and the cord as far 
as it can be followed is the only operation that promises a permanent 
result. Kocher has observed cases in which the disease did not recur 
for four and a half, eight and a half, and ten and a half years after 
operation. 

Penis. — Carcinoma of the prepuce and of the glans penis is observed 
in men past fifty years of age. Kaufmann estimates that one-third of all 



344 



PATHOLOGY AND TREATMENT OF TUMORS. 



the cases occur during the sixth decennium. Occasionally the tumo 
originates in Tyson's glands. Such a case is referred to by Tyson 
Usually the tumor commences in the epithelial layer of the skin an< 
of the glans penis, and presents itself as a cauliflower tumor with grea 
induration at its base. The surface ulcerates early, and is usually thi 
seat of a very offensive discharge. 

The histological structure of carcinoma of the penis (Figs. 226, 227 
resembles essentially squamous-celled carcinoma of the skin in othe 
localities. Paget saw in a number of cases carcinoma of the penis pre 
ceded by balanitis. In other cases the disease starts in a pre-existing 




Fig. 226.— Squamous-celled carcinoma of the penis ; X 150 (after Perls) : to the right, normal skin ; to th< 
left, proliferating epithelial projections with numerous cancer-nests. 

inflammatory lesion of a more circumscribed nature. Injuries sustainec 
during coitus, during masturbation, and by friction of the clothing ma> 
furnish the exciting causes in other cases. 

It was formerly doubted that carcinoma of the penis could give rise 
to regional infection. Kaufmann and Gussenbauer have shown thai 
carcinoma of this organ pursues the same course as carcinoma of the 
skin in other localities — namely, that regional infection occurs, as a rule 
late, but that it is sure to ensue if the disease is allowed to pursue its 
own course. The writer has seen regional infection much more fre- 
quently in carcinoma of the penis than in carcinoma of the lip. The 
inguinal glands on both sides eventually become involved — a fact which 
has led to the conviction that it is necessary in most cases to resort al 
once to clearing out of the inguinal glands in all cases of carcinoma 
of the penis in which a radical operation is performed. 



CARCINOMA. 



345 



Amputation of the Penis for Carcinoma. — If the carcinoma is limited 
to the prepuce, and no evidences of lymphatic affection are present, the 
organ should be amputated behind the corona glandis. The penis is 
constricted at its base with a rubber cord or tube to render the opera- 
tion bloodless. The section through the penis should be made with 
the knife in such a manner as to secure for the stump a cutaneous 
covering. The writer generally makes an oval anterior flap with which 




Fig. 227. — Papillary carcinoma of penis ; X 10 (after Karg and Schmorl). Between the enlarged papillse, 
covered by thickened layers of epithelial cells, are found infiltrations of epithelial cells which in the vascular 
connective tissue show distinct cancer-nests. 

to cover the corpora cavernosa. The mucous membrane of the ure- 
thra is stitched to this flap and to the adjacent skin. The dorsalis penis 
artery is ligated. The hemorrhage from the corpora cavernosa, at first 
profuse, yields to compression, hot water, and the sutures. A small 
dressing held in place with a number of strips of adhesive plaster fin- 
ishes the operation. Rest for a few days in bed must be enforced. 
The suturing of the flap and the urethra should be done with fine cat- 
gut sutures, so as to obviate the necessity of removing them. 



346 PATHOLOGY AND TREATMENT OF TUMORS. 

If the body of the penis is affected by extension of the primary 
tumor of the prepuce or the glans penis, the organ should be amputated 
close to the pubes, and at the same time the inguinal glands on both 
sides should be removed. The amputation is made with the knife and 
in the manner just described, but an outlet for the urethra is established 
in the perineum, as first recommended by Thiersch. The urethra is 
isolated, is brought out through a small buttonhole behind the 
scrotum, and is firmly anchored to the skin with a few sutures. In a 
case that recently came under the writer's observation the disease had 
extended along the penis and had involved the mons veneris as well as 
the glands in both inguinal regions. In this case the entire penis, part 
of the mons veneris, and both testicles were removed, and the posterioi 
part of the scrotum was utilized as a covering for the enormous wound 
The incision was extended on both sides the whole length of Poupart's 
ligament, and was joined over the large femoral vessels by a vertical 
incision reaching to the apex of Scarpa's triangle. The whole chain 
of glands on each side was removed with the penis in one continuous 
piece. The urethra was stitched to the margins of a small opening hi 
the perineum. The shock from the operation required active treatment 
by stimulants. The patient rallied in the course of six hours and made 
an excellent recovery. Three months after the operation he returnee 
to the hospital greatly improved in general health, but with a recurrence 
in the left groin. A second operation was performed, and a section of 
the internal saphenous vein was removed with the carcinomatous tissue 
by which it was surrounded. Six months after since the second opera- 
tion there were no signs of further recurrence. 

Ovary. — Carcinoma of the ovary occurs after the period of puberty 
as a comparatively rare affection as a primary tumor, in cystic tumors 
and as the result of extension by contiguity of a carcinoma of ar 
adjacent organ. Olshausen describes papillary carcinoma of the ovarj 
as a primary tumor. The same author makes the statement that Kleb; 
and Spencer Wells first called attention to this form of carcinoma of 
the ovary. The carcinoma appears as a malignant form of papillarj 
or proliferating cystoma. Marchand has shown that this form of cysti< 
tumor of the ovary gives rise to metastasis. In one case of papillar) 
cyst of the ovary in a woman thirty-five years of age the writer founc 
the tumor extensively adherent to the anterior abdominal wall. Th( 
tumor was, however, completely removed, and the patient made a gooc 
recovery. Six months later she again entered the hospital, and upor 
examination quite an extensive carcinoma was found in the scar jus 
below the umbilicus. A considerable portion of the entire thicknes: 
of the abdominal wall, and including the whole scar, was resected. Shi 



CARCINOMA. 



347 



recovered without any untoward symptoms, but died a few months later 
from diffuse carcinosis of the peritoneum. 

Rokitansky described a case of carcinoma of the ovary that started 
in a corpus luteum. 

The occurrence of carcinoma in cysts, and the resemblance anatom- 
ically of the carcinomatous and adenomatous proliferating cysts of the 
ovary, make it veiy difficult to distinguish, from the naked-eye appear- 
ances of certain cysts of the ovary, between malignant and non-malig- 
nant tumors. From a histological standpoint this difficulty is increased 
because endothelial tumors of a malignant character are included by 
some authors under the head of carcinoma. Endothelioma, which was 

. S- 

«#PC^^: •■•■-. ' 





Fig. 228.— Carcinoma of the ovary; X 75 (Surgical Clinic, Rush Medical College): a, scanty connective- 
tissue stroma ; b, nests of epithelial cells ; c, small colloid cysts ; d, blood-vessel. 

first described by Birch-Hirschfeld as carcinoma of the lymphatics, con- 
stitutes a tumor composed of tissue derived from the mesoblast, and it 
will again be referred to in the section on Sarcoma. Carcinoma as a 
primary tumor of the ovary undoubtedly originates, as does adenoma, 
in a remnant of the fetal ducts (Fig. 228). The stroma is alveolated 
and is usually scanty ; the cells are numerous, filling the alveoli and 
infiltrating the stroma. The tumor is soft and grows rapidly. Colloid 



348 PATHOLOGY AND TREATMENT OF TUMORS. 

degeneration affecting both the parenchyma and the stroma of the 
tumor results in the formation of cysts. Diffuse carcinosis of the peri 
toneum takes place when the tumor perforates the capsule of the ovary 
Tumor-cells and fragments of tumor-tissue are disseminated over th( 
peritoneal surfaces by the peristaltic action of the intestines ; these 
cells and fragments of tissue become implanted at different places 
and establish in this manner independent centres of tumor-growtr 
everywhere. 

Ascites is often the first symptom which induces the patient to seel 
medical advice. Ascites in the female occurring independently of the 
existence of organic disease of the liver, heart, or kidneys indicates the 
existence of either peritoneal tuberculosis, malignant disease of the 
ovary, or a movable solid tumor of the uterus or the ovaries. If the 
patient is advanced in years, the possibility of the primary affection 
being of a malignant character is greatly increased. Carcinoma of the 
uterus is exceedingly prone to extend to the ovaries. Winckel records 
a case in which, a year and a half after amputation of the cervix foi 
carcinoma, the disease made its appearance in one of the ovaries, while 
no local recurrence had taken place. 

Many gynecologists are opposed to radical measures in the treat- 
ment of carcinoma of the ovary. This sense of helplessness on the 
part of the surgeon when confronted by such a case has been createc 
largely by the unfavorable experience of late operations. Usually 
before a laparotomy is made, the disease has extended from the ovary 
to the adjacent organs. The broad ligament is often extensively impli- 
cated. The adherent omentum frequently shows evidences of extensive 
involvement, and sometimes diffuse miliary carcinosis is present. If the 
general condition of the patient is such as to warrant an exploratory 
incision, this should always be done, if for no other purpose than tc 
make a positive diagnosis. It is just possible that the ascites and the 
other conditions which have induced the surgeon to make a diagnosis 
of carcinoma may have been produced by other pathological conditions 
which are within reach of successful treatment by direct measures 
The patient should therefore be given the benefit of the doubt by i 
resort to an exploratory incision. It appears that temporary relief anc 
prolongation of life have been obtained in cases in which the disease 
returned later. The writer can recall at least three instances in which 
by the removal of a carcinomatous tumor of the ovary with extensive 
adhesions, great relief was afforded and life was prolonged for from si> 
months to a year. If the disease is limited in extent, the success of ar 
operation should be the same as in operations for carcinoma of othei 
organs similarly situated. If the attachments are such that the remova 



CARCINOMA. 349 

of the tumor would place the life of the patient in imminent danger, 
the operator should go no further, and should close the wound after 
having made a positive diagnosis. 

Uterus. — Carcinoma of the uterus was known to the ancient 
authors, and has been described elaborately by Hippocrates, Celsus, 
Galen, ^Etius, and others. In more recent times animated discussions 
have been carried on in regard to its starting-point. Cancroid, papil- 
lomatous carcinoma, scirrhus, and medullary carcinoma of the uterus 
have been regarded as distinct varieties of carcinoma. The histo- 
genetic origin of carcinoma of the uterus, like that of carcinoma of 
other mucous surfaces, can be traced either to a matrix of embryonic 
cells in the epithelial lining or to a matrix representing the glandular 
appendages of the uterus. 

Histogenesis and Histology. — The cauliflower excrescences of the 
cervix uteri, or the papillomatous variety of carcinoma, have been recog- 
nized for a long time as one of the most common malignant tumors 
of the uterus. How much confusion has existed in separating the 
malignant from the benign papillary tumors is evidenced from a de- 
scription of them by Virchow in 185 1 : 

" One must distinguish three different papillary tumors of the os 
uteri : the simple, such as Frerichs and Lebert have seen ; the cancroid ; 
and the cancerous : the first two forms together constitute the cauli- 
flower growth. This begins as a simple papillary tumor, and at a later 
period passes into cancroid. At first one sees only on the surface 
papillary or villous growths, which consist of very thick layers of 
peripheral, flat, and deeper cylindrical epithelial cells, and a very fine 
interior cylinder formed of a scanty stroma of connective tissue with 
large vessels. The outer layer contains cells of all sizes and stages 
of development, some of them forming great parent structures with 
endogenous corpuscles. The vessels are for the most part colossal, 
very thin-walled capillaries, which form either simple loops at the apices 
of the villi, between the epithelial layers, or toward the surface develop 
new loops in constantly increasing number, or, lastly, present a retic- 
ulate branching. At the beginning of the disease the villi are simple 
and close pressed, so that the surface appears only granulated, as 
Clarke describes it : it becomes cauliflower-like by the branching of 
the papillae, which at last grow out to fringes an inch long, and may 
present almost the appearance of a hydatid mole. After the process 
has existed for some time on the surface, the cancroid alveoli begin to 
form deep strings between the layers of the muscular and the con- 
nective tissue of the organ. In the early cases I saw only cavities 
simply filled with epithelial structures ; but in Kiwisch's case there 



35° 



PATHOLOGY AND TREATMENT OF TUMORS. 



were alveoli on whose walls new papillary branching growths were 
growing — a kind of proliferous arborescent formation." 

It will be seen from this description that the cauliflower excrescence: 
in the two conditions distinguished by Virchow illustrate the usua 
clinical course of the most malignant growths of the cervix uteri 
The growths which he calls " simple papillary tumors " represent the 
same form of carcinoma of the skin. The outgrowth of the papillary 
excrescences is always attended by infiltration of the deeper structures 
(Fig. 229). The tumor is composed of enlarged papillae covered b> 




Fig. 229. — Papillary cancer of the cervix: pavement epithelium of the external OS; section, natural sizi 

(after Pozzi). 



squamous epithelial cells in greatly thickened layers. The enlargec 
papillae form the branching projections. The tumor begins in that pari 
of the cervix that is below the vaginal insertion, after it starts fron 
cylindrical epithelium which has invaded the surface. It remains foi 
a long time local, but later local and regional infection is sure to take 
place, extending to the vagina, the body of the uterus, the pelvic con- 
nective tissue, and the lymphatic glands. 

In other cases the carcinoma appears as an induration without an} 
papilliform projections. Ulceration in the centre of the growth take: 
place at an early stage, and continues to spread toward the peripherj 
as well as in the direction of the base of the ulcer. These are the case; 
which correspond with the flat, squamous-celled carcinoma of the skin 

Carcinomata originating in the mucous membrane of the cervica 
canal begin in the glands, and are composed of cylindrical cell: 
arranged in tubular form in a stroma very variable in its relativi 
proportions to the parenchyma of the tumor (Fig. 230). Primary car 
cinomata of the mucous membrane of the cervical canal and of th< 



CARCINOMA. 



351 



uterine cavity histologically resemble each other almost perfectly. 
The structure is in imitation of the mucous glands. The starting-point 
of the tumor is in a matrix of embryonic cylindrical epithelial cells that 
pre-exists in one of the glands or in their immediate vicinity, or that is 



<*p- 



*: 



J- 



•iH 



SgSK 



■j£' 














Fjg. 230. — Carcinoma of the cervix uteri ; X 12 (after Karg and Schmorl) ; vertical section through the 
carcinomatous anterior lip of the cervix. The carcinoma commenced in the vaginal portion of the cervix. 
The mucous membrane of the cervical canal is completely destroyed. The tumor projects from the cervical 
canal, in the form of cauliflower excrescences (a), beyond the level of the squamous cells (c) of the anteriur 
lip ; at other points it infiltrates, in the form of solid strings of cells and nests of cells, the vascular mus- 
cularis (d) ; e, remnants of uterine glands lined with cylindrical cells. 

formed later in these localities by post-natal causes. Boyce had an 
opportunity to study the incipient stage of a tumor with such an origin 
(Fig. 231). The illustration represents a complete uterine gland, the 
mouth of which (a) is stopped by an epithelial overgrowth of the 
columnar lining, and on whose wall (at b) a plaque of proliferated epi- 



352 



PATHOLOGY AND TREATMENT OF TUMORS. 



thelium has formed in the midst of typically columnar cells. It is 
the beginning of a cancerous change which elsewhere in the uteru: 
has advanced to completeness. Where the change is complete the 




Fig. 231. — Uterine gland, showing very early malignant overgrowth of the columnar epithelium at a and t 
(after Boyce). (Ohj. 1 inch, with eye-piece.) 

glands have been converted into solid epithelial cylinders; these 
together with the proliferating epithelium on the surface, have branchec 
deeply into the stroma (Fig. 232). 




Fig. 232. — Cylindrical-celled carcinoma from the upper part of the cervix, invading the fundus ; X *5' 
(after Cornil) : m,e, hypertrophied glands of the body of the uterus, like those of chronic metritis ; t, en 
larged glandular cavity, the walls showing many layers of epithelium ; b, adjacent gland-wall in a simila 
state ; v, vessels ; c, connective tissue. 

Cylindrical-celled carcinoma is much more malignant than the squa 
mous-celled variety. Carcinoma of the cervical canal creeps along the 
mucous membrane into the cavity of the uterus. The intra-uterin< 
part of the tumor presents under the microscope a structure similar t( 
that of the primary tumor (Fig. 233). 

Primary carcinoma of the body of the uterus is a much rarer affec 
tion than carcinoma of the cervix. Clinically, carcinoma of the uterim 
cavity presents itself in two forms, the circumscribed (Fig. 234) and th< 
diffuse (Fig. 235). In the circumscribed form the tumor often attain; 
considerable size before it breaks down, and frequently it assumes ; 



CARCINOMA. 



353 






J 










FrG. 233.— Cylindrical-celled carcinoma of the body of the uterus, extending from the cervix ; X 150 
(after Cornil) : c, c, connective tissue ; a, cavity full of cells, the external layer being cylindrical : these cells 
have a tendency to become detached from the wall, well seen at o ; f, cavity with mucous cells, and larger 
cells in mucous degeneration, 

polypoid shape. In the diffuse variety the mucous membrane is exten- 
sively involved from the beginning, and the disease infiltrates the mus- 




Fig. 234. — Carcinoma of the uterine mucous mem- 
brane, circumscribed form (after Pozzi). 




Fig. 235. — Carcinoma of the uterine mucous mem- 
brane, diffuse form (after Pozzi). 



cular tissues in all directions, resulting in a uniform pear-shaped 
enlargement of the body of the uterus. 
23 



354 



PATHOLOGY AND TREATMENT OF TUMORS. 



The structure of a primary carcinoma of the uterine mucous mem 
brane, like that of a carcinoma of the cervical canal, is usually in imita 




Fig. 236. — Primary carcinoma of the uterus ; X 120 (after Pozzi) : b, b, lobules of the tumor ; m, lobule; 
showing empty spaces, which are either transverse sections of vessels or cavities filled with cells in mucou: 
degeneration ; n, smaller alveoli of the tumor. Nearly all these epithelial cells have a tendency towart 
isolation by the walls of the vessels that enclose them. 

tion of the uterine glands. Cylindrical cells are arranged in a tubulai 
form in an alveolated stroma (Fig. 236). The cylindrical cells art: 




Fig. 237.— Primary carcinoma of the uterine body ; X 300 (after Cornil) : a, numerous layers of stratifiet 
epithelium, the deepest being cylindrical ; e, e, cells with karyokinesis ; /, muscular tissue of the uterus, 01 
which the cylindrical cells are directly implanted. 

arranged in the tubules in one or more layers. If the layers art 
numerous, the cells most distant from the matrix become flattened anc 



CARCINOMA. 355 

resemble squamous or pavement epithelium (Fig. 237). Mucous and 
colloid degeneration leads to dilatation of the tubules and the formation 
of cysts of small size. The stroma often undergoes similar changes. 
The infiltration of the cervix and body of the uterus imparts to the 
affected organ that characteristic hardness with which the surgeon 
becomes so familiar as an important point in differential diagnosis. 
The formation of large tumors is rendered impossible by the destruc- 
tive ulceration which sets in at an early stage and continues in a pro- 
gressive manner. In the papillary form the copious vegetations slough 
off, leaving large ulcerating defects. 

Etiology. — Schroeder ascertained that 33 per cent, of all women who 
die of carcinoma succumb to carcinoma of the uterus. The only organs 
more frequently affected by carcinoma are the stomach and the mam- 
mary gland. Wagner estimated that of all persons who die of carci- 
noma, in one-fourth of them the uterus is the seat of the disease. 
From these statistics it is evident that the uterus is one of the organs 
which presents, next to the stomach, conditions, congenital or other- 
wise, most favorable to the development of carcinoma. The fifth 
decennium is the time of life most predisposed to the affection. A 
closer study of the statistics shows that the first five years after the 
cessation of menstruation furnish the largest contingent of cases. An 
hereditary predisposition was traced, according to different authors, in 
from 7.6 to 1 3 per cent. Winckel called special attention to the frequent 
occurrence of carcinoma of the uterus in tubercular families — another 
proof of the fallacy of Rokitansky's assertion that tuberculosis and 
carcinoma do not occur in the same person at the same time. Carci- 
noma occurs more frequently in married than in single women, and 
more frequently in sterile women than in those who have given birth to 
children. Of the women who have borne children, those who have 
passed most frequently through childbed are most disposed to carci- 
noma of the uterus. Difficult or instrumental deliveries and abortions 
appear to exert an etiological influence. These different etiological 
influences have been studied by Winckel on the hand of an extensive 
clinical material that came under his own observation. There can be 
no question that trauma, inflammatory affections, and benign tumors, 
which are so frequently found in the cervix, constitute an important 
element in the production of carcinoma. The most important cause, 
however, to explain the frequency with which carcinoma selects this 
locality, is the fact that in the embryo the squamous epithelium of the 
sinus urogenitalis blends with the cylindrical epithelium of Miiller's 
ducts at the external os of the cervix. It is at the point of junction of 
the epithelial cells of different embryonal origin and of different shape 



356 PATHOLOGY AND TREATMENT OF TUMORS. 

and function that carcinoma most frequently takes its starting-point, 
Embryonal cells are here in excess or they are displaced, and become 
later the essential tumor-matrix. 

The reasons why carcinoma of the cervix appears in preference aftei 
the menopause are the same as Thiersch has advanced for carcinoma 
of the lip. The shrinking submucous connective tissue loses at this 
time its physiological resistance, thus opening pathways for invasion by 
epithelial cells. Emmet has called attention to laceration of the cervix 
as a cause of carcinoma. The writer is strongly inclined to believe 
that a laceration of the cervix may not only act as an exciting cause 
but that, in addition, it may furnish the essential matrix of embry- 
onic epithelial cells. It is not difficult to understand that during the 
healing of a laceration of the cervix new embryonal cells may become 
buried in the scar-tissue in an immature state, and remain in this con- 
dition, constituting a tumor-matrix of post-natal origin. E. Martin 
believes that acute infectious lesions of the vagina and the uterus, like 
gonorrhea, have an influence in the causation of uterine carcinoma — an 
opinion which receives the support of Winckel and others. 

Symptoms and Diagnosis. — The symptoms which point to the exist- 
ence of carcinoma of the uterus are (i) hemorrhage, (2) profuse anc 
often very fetid vaginal discharge, (3) pain, (4) dysuria, and (5) recta! 
tenesmus. 

If the patient has not ceased to menstruate, menstruation is profuse 
and prolonged. Greater significance attaches, however, to the occur- 
rence of hemorrhage between the menses. Bleeding during the interval 
occurring spontaneously or provoked by active exercise, by the use of 
the vaginal syringe, or by coitus, in a woman past thirty-five years of 
age is very suggestive of the existence of a carcinoma of the uterus 
and should induce the medical attendant to make a thorough examina- 
tion. The occurrence of hemorrhage after the menopause has a similai 
diagnostic significance. 

A profuse watery discharge, stained at times with blood, is one of 
the earliest external evidences of papillary carcinoma of the cervix 
The discharge is often very irritating, producing excoriation of th< 
external genital organs, and often a catarrhal vaginitis. When the dis 
ease has advanced to extensive ulceration, or the papillary excrescence: 
have become gangrenous, the discharge is always exceedingly fetid anc 
profuse ; at this time it also frequently contains fragments of cast-ofl 
tumor-tissue. 

The pain, of a dull, aching, burning, or lancinating character, i: 
referred most frequently to the back, the lower part of the abdomen 
the hips, the iliac regions, and the thighs. 



CARCINOMA. 357 

The retention of secretions in the uterine cavity by the blocking of 
the cervical canal by the tumor-tissue causes expulsive pains. If the 
carcinoma presses upon the bladder or has reached this organ by 
extension, urinary disturbances set in, varying in intensity from a desire 
to pass the urine more frequently than usual to the involuntary escape 
of urine through a fistula produced by destruction of the posterior 
bladder-wall by the tumor. The function of the rectum is disturbed 
by pressure or by the extension of the disease from the uterus to the 
rectum. 

Constipation, tenesmus, and the escape with the feces of mucus or 
of mucus stained with blood are some of the indications showing the 
existence and extent of uterine carcinoma. If the disease has extended 
to the pelvic connective tissue or the peritoneum, it presents many 
symptoms and signs of parametritis and pelvic peritonitis — affections 
which must be excluded carefully in the differential diagnosis. Exten- 
sive local and regional infection is indicated further by great cedema of 
one or both lower extremities, caused by compression or thrombosis 
of one or more of the large veins in the pelvis, by ascites, by tympan- 
ites, and by carcinoma of the external genitals. Metastatic tumors in 
distant parts of the body would indicate that general infection has taken 
place. 

It is unfortunate that the onset of the disease is so insidious, as 
patients, as a rule, consult the physician only after the disease has 
manifested itself by symptoms which belong to its advanced stages. 
Unless discovered accidentally in the examination for obscure pelvic 
affections, carcinoma of the uterus presents itself to the surgeon in the 
majority of cases in its advanced stages. As most if not all of the 
symptoms that have been detailed may be simulated by benign tumors 
of the uterus and by inflammatory affections involving this organ and 
its appendages, a reliable diagnosis must rest upon a thorough exam- 
ination. 

In advanced cases, when the lower segment of the uterus is the seat 
of fungous masses or of a deep excavation with an infiltration of stony 
hardness at its base extending from the uterus to the parauterine con- 
nective tissue on both sides, completely immobilizing the organ, a 
positive diagnosis can be made by the mere touch of the finger. It is 
different in cases in which the disease is limited to perhaps one lip of 
the cervix, or where the disease originated primarily in the mucous 
membrane of the uterine cavity. In such cases it is sometimes exceed- 
ingly difficult to differentiate between chronic inflammatory affections, 
benign tumors, and carcinoma. 

Laceration of the cervix with hypertrophy of one or more of its 



35§ 



PATHOLOGY AND TREATMENT OF TUMORS. 



lips, and ectropion of the cervical mucous membrane with erosion, hav 
frequently been mistaken for carcinoma. A hypertrophic lip of th 
cervix covered by papillary erosions presents to the palpating finger o: 
passing it lightly over the surface a velvety softness, while on deepe 
pressure the hypertrophied tissues feel uniformly dense, but lack th 
stony hardness of carcinoma 
(Fig. 238). The carcinomatous 
cervix feels not only hard but 
nodulated, and if ulceration has 
taken place the surface of the 





Fig. 238. — Broad erosions of both lips of 
cervix, with numerous glandular openings 
(after Winckel). 



Fig. 239. — Papillary carcinoma of cervix limited almos 
entirely to the anterior lip (after Winckel). 



ulcer is uneven and hard (Fig. 239). If the disease involves both lips 
at the same time and is limited in extent, the opening of the cervical 





Fig. 240. — Papillary carcinoma of both lips of the 
cervix {after Winckel). 



-Large retention-cysts of both lips of 
the cervix (after Winckel). 



canal is then surrounded by a ring-like induration of great firmness 
that does not yield on attempting to insert the tip of the index finger 
(Fig. 240). 

Retention-cysts of the external os of the cervical canal might be 
mistaken for carcinoma, as on palpation they feel quite firm, but lack 
the induration so characteristic of carcinoma, and on deep pressure a 



CARCINOMA. 



35' 



sense of elastic resistance is produced. These cysts are also usuall; 
multiple, while carcinoma extends from one centre (Figs. 242, 243). 




Fig. 242. — Beginning cancer of the cervix, ulcer- 
ative form (after Pozzi). 




Fig. 243. — Cancer of the cervix, nodular fori 
(after Pozzi) : p, zone of intact pavement epith< 
lium ;/, cancerous nodule ; a, external os ; c, cervi) 



In doubtful cases a diagnosis must be made by the use of the micro 
scope. A small fragment of tissue near the margin of the supposet 
tumor is removed, and from it sections are made. In carcinoma thi 



Fig. 244. — Atypical columnar epithelioma derived from uterine glands (after Boyce) : a, the cancer-cylinder 

(Obj. i inch, without eye-piece.) 



section will show atypical proliferation of epithelial cells in the form of 
solid cylinders and epithelial nests in the vascular stroma. In papillary 
erosions the section will show an increase of glandular structure, but 
the epithelium is separated from the submucous vascular connective 



360 



PATHOLOGY AND TREATMENT OF TUMORS. 



tissue by the membrana propria. No epithelial cells are found in direc, 
contact with vascular connective tissue. 

Primary carcinoma of the body of the uterus is very rare, and espe- 
cially so in women less than fifty years of age. It is attended bj 
enlargement of the uterus, profuse and often fetid vaginal discharge 
and fitful attacks of hemorrhage. As some of these symptoms attenc 
adenomatous disease of the mucous membrane, it is often necessary tc 
remove with the sharp curette fragments of tissue for examination 
under the microscope. In adenoma the epithelial cells will be found tc 
occupy their normal relative position to the basement membrane, while 
in carcinoma the epithelial cells, almost always of the cylindrical variety, 
will be found in and among the vascular structures and arranged in a 
tubular form (Fig. 244). Retained placental tissue and myoma of the 
uterus undergoing sloughing are conditions which might lead to errors 
in diagnosis, and they must be considered carefully in making a differ- 
ential diagnosis between primary carcinoma of the body of the uterus 
and other intra-uterine affections. 

Supravaginal Amputation of the Cervix Uteri for Carcinoma. — The 
first supravaginal excision of the cervix uteri for carcinoma was made 
by Osiander. The operation was later perfected by C. J. M. Langen- 
beck and by Schroeder. This operation should be restricted to cases 

of carcinoma beginning upon the 
vaginal portion of the cervix and in 
which the disease has not extended 
to the body of the uterus. Surgeons 
are not agreed as to the value of this 
operation in the treatment of uterine 
carcinoma. The combined statistics 
representing cases from the practice 
of a number of able surgeons show 
a mortality of about 11.5 per cent. 
Some of the ardent advocates of this 
operation claim that in nearly half of 
the cases the carcinoma did not return 
after operation. Such a statement, 
however, must be accepted with a good 
deal of allowance. On the contrary, 
the champions of hysterectomy under- 
rate the value of this operation. Com- 
mon sense would dictate that in a 
limited carcinoma of the external os it is no more necessary to remove 
the entire uterus than it would be to extirpate the whole of the lower lip 




Fig. 245. — Schroeder's supravaginal ampu- 
tation of the cervix for carcinoma, showing the 
extent of the excision and the ligature of the 
lower branch of the uterine artery (after Pozzi). 



CARCINOMA. 361 

in a beginning carcinoma of the lip. Here as elsewhere the surgeon 
must show good sense and judgment in selecting the cases for partial 
and those for complete removal of the uterus for carcinoma. Schroeder's 
operation is the one that promises the best results in well-selected cases. 
The uterus is drawn down to the vulva by vulsellum forceps, and 
a strong loop of thread is passed through and above each of the lateral 
culs-de-sac (Fig. 245). These loops serve to draw the parts down and 
to compress the uterine artery. The cervix is then isolated, through 
a circular incision made at the vaginal insertion, as far as the internal os. 
Spirting vessels are at once tied. The dissection is made as far as 
possible by the use of blunt instruments, to guard against wounding 
the bladder or the rectum or opening unintentionally the peritoneal 
cavity. The anterior portion of the cervix is removed first, when the 
vaginal mucous membrane is stitched to the mucous membrane of the 
cervical canal. The same is done after the amputation of the posterior 
half of the cervix. Schroeder has excised with the cervix the upper part 
of the vagina when the disease had extended in that direction. Some 
surgeons employ no sutures after amputation of the cervix, but follow 
the use of the knife by that of the cautery (Koeberle) or of chloride of 
zinc (Van de Warker). If all the diseased tissue can be removed — 
and these are the cases which are adapted for supravaginal amputa- 
tion — it is advisable to suture the vaginal mucous membrane to the 
mucosa of the cervical stump, as otherwise a stenosis or a complete 
obliteration of the cervical canal may become a source of trouble and 
an indication for more operating in the future. The writer has seen at 
least two cases of supravaginal amputation of the cervix for carcinoma 
in which the suturing was omitted, and in which complete obstruction 
by cicatricial contraction gave rise to great pain during the menstrual 
period, as all the menstrual discharge escaped into the peritoneal cavity, 
causing repeated attacks of pelvic peritonitis. In one of these cases 
removal of the uterine appendages disclosed both of the tubes greatly 
distended, the lumen at the fimbriated extremity having become greatly 
narrowed by firm adhesions, the remnants of repeated attacks of cir- 
cumscribed peritonitis. 

J \iginal Hysterectomy for Carcinoma of the Uterus. — C. J. M. Langen- 
beck in 18 13 made the first complete vaginal hysterectomy for carci- 
noma. Sauter and Dubourg appear next in the list of surgeons who 
undertook this operation. Vaginal hysterectomy was revived and per- 
fected in 1878 by Czerny. A radical operation for carcinoma of the 
uterus involving more than the cervix and limited to the uterus can be 
performed with less difficulty and greater safety by the vaginal than 
by the abdominal route. Freund's abdominal hysterectomy for carci- 



362 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 246. — Vessels of the uterus : uterine and utero-ovarian arteries (after Pozzi). 

noma has been replaced almost entirely by vaginal hysterectomy. Strict 
antiseptic precautions are necessary when the abdominal cavity is to be 




Fig. 247. — Vaginal hysterectomy : first step, opening the posterior cul-de-sac and suture of the peritoneur 
to the vaginal mucous membrane (after Martin). 



CARCINOMA. 



363 



opened in the removal of a carcinomatous uterus. The vagina and the 
external genitals should be disinfected in the usual manner, and if the 
carcinoma has ulcerated extensively, a preliminary scraping is neces- 
sary for the purpose of removing necrosed infected tissue that would 
escape the ordinary means of disinfection. The patient should undergo 
preparatory treatment as for laparotomy for a number of days. Bladder 
and rectum should be emptied before the operation is commenced. 

The patient must be placed in the lithotomy position, the thighs being 
well separated and properly immobilized. Hegar's speculum and re- 




Fig. 248. — Vaginal hysterectomy : second step, ligation of the uterine artery (after Martin). 

tractors, made for this special purpose, are best adapted for securing 
access to the uterus. The modern improved technique of vaginal 
hysterectomy has special reference to the prevention and arrest of 
hemorrhage. The principal vessels concerned in this operation are 
well shown in Figure 246. The uterus is secured and drawn down to 
the vulva in the same manner as in supravaginal amputation of the 



364 PATHOLOGY AND TREATMENT OF TUMORS. 

cervix. The operation is commenced by opening the cul-de-sac 01 
Douglas by a curved incision behind the cervix at its junction wit! 
the vagina, when the vaginal mucous membrane is sutured to thi 
peritoneum (Fig. 247). The suturing arrests the parenchymatous anc 
venous hemorrhage completely. The next step (Fig. 248) consists ii 
ligating the uterine artery on both sides en masse. The left indej 
finger is inserted through the wound, and the exact location of th< 
artery is ascertained by the pulsations ; then, with a large curved needle 
armed with strong silk, the arteiy is included in a mass of tissue a 
each angle of the wound and is secured by drawing the ligature tightly 
The cervix is then drawn backward and downward, and, by an incis- 
ion at a safe distance from the palpable margin of the tumor, the circulai 
incision is completed, the point of the knife being directed against the 
cervix to avoid wounding the bladder. The dissection between the 
bladder and the cervix is made chiefly by the use of the finger anc 
of blunt instruments. Hemorrhage is arrested by points of suture 
on the cut surface of the tissues. The uterus is now retroverted suf- 
ficiently to bring the broad ligaments within easy reach, when they are 
tied in three parts. The uterus is now, by means of scissors, severec 
from all attachments, including the peritoneal reflection between ii 
and the bladder, which attachment so far has been reserved to guarc 
against infection. Prolapse of the intestines is prevented by elevating 
the pelvis or by means of a large sponge well secured in long hemo- 
static forceps. 

The wound should be closed on each side by one or two sutures 
leaving an opening in the centre for an iodoform-gauze drain. If 
ovaries or tubes present conditions requiring operative treatment, they 



Fig. 249.— Bowed forceps for compression of the broad ligaments in vaginal hysterectomy (after Doyen). 

should be removed ; otherwise it is better to limit the operation to the 
removal of the uterus. If the bladder or the rectum should be injured 
during the operation, the visceral wound must be sutured. After com- 
pletion of the operation the vagina is lightly packed with iodoform 
gauze. The packing and dressing should not be removed for from 
three to five days unless hemorrhage or infection demands earlier 
interference. Ligation of the broad ligaments and blood-vessels is the 



CARCINOMA. 



365 



correct surgical way in which to prevent and arrest hemorrhage in 
vaginal extirpation of the uterus. 

Pean has substituted for the ligature long compression-forceps 
(Fig. 249). After detaching the cervix much in the same way as has 
been described, the broad ligament near the uterus is grasped with 
long, slightly curved catch-forceps, as shown in Figure 250. The for- 
ceps are prevented from un- 
locking by tying the handles 
together with a strip of gauze. 
After removal of the uterus 
the vagina is packed with gauze 
and the forceps are incorpo- 
rated in the external antiseptic 
dressing. The forceps are re- 
moved at the end of the second 
day. 

Many surgeons have adopt- 
ed Pean's method of control- 
ling hemorrhage in vaginal 
hysterectomy by permanent 
forceps pressure, but the pro- 
cedure is open to a number 
of serious objections which do 
not apply to the use of the 
ligature, the most important 
being insecurity against second- 
ary hemorrhage from slipping of the forceps and inability to carry out 
aseptic precautions to the required extent. The writer has always relied 
on the ligature, and has had no reason to change his views concerning 
its superiority over the forceps in the permanent arrest of hemorrhage 
in vaginal hysterectomy. 

Extirpation of the carcinomatous uterus through the sacral route 
was first practised by Hochenegg and is strongly endorsed by Czerny. 
The sacral resection is made in the same way as advised by Kraske for 
extirpation of carcinoma of the rectum. The sacral operation would 
certainly appear to present great advantages when the lymphatic glands 
and the connective tissue behind the uterus have become infected, as it 
secures better access to the retro-uterine tissues than does the vaginal 
operation. 

Extraperitoneal enucleation, first practised by the older Langenbeck, 
and recently revived by Frank and Lane, has no future in the operative 
treatment of carcinoma of the uterus. 




Fig. 250. — Vaginal hysterectomy : application of for- 
ceps and section of the base of the broad ligament (after 
Pean). 



3 66 



PATHOLOGY AND TREATMENT OF TUMORS. 



In inoperable cases of carcinoma of the cervix and uterus — and a 
such should be considered all cases in which, from the extent of th 
disease, complete removal of all infected tissues cannot be effected b; 
either vaginal or sacral hysterectomy — the removal of fungous masse 
with a sharp spoon, followed by thorough cauterization with thi 
Pacquelin cautery, constitutes an important palliative measure. 

External Female Genital Organs. — Carcinoma of the external gen 
ital organs of the female is a comparatively rare affection. Its priman 

starting-point may be either th< 
labium majus, the labium minus 
or the clitoris. Among 747c 
women suffering from carci 
noma, Winckel found that tht 
vulva was the primary seat of th< 
disease in 72, or about 10 pe: 
cent, of all the cases. The tu 
mor begins as a firm nodule ir 
the skin, with an indurated base 
The tumor is covered at firsi 
by thickened layers of epithelia 
cells, which in the centre of the 
growth soon disappear by ulcera- 
tion. Carcinoma of the vulva 
according to Klob and Winckel 
is always composed of squamous 
epithelial cells. As soon as ul- 
ceration has occurred, the oppo- 
site surface with which the tumoi 
may come in contact is often 
similarly affected. The tumoi 
does not attain any considerable 
size, as the older portions are destroyed by ulceration. The tumoi 
represented in Figure 25 1 was removed by Winckel. In another case 
the same authority satisfied himself that the carcinoma had originated 
in a congenital wart of the clitoris. The transformation of a wart of 
the lesser labium into a carcinoma is well shown in Figure 252. 

Lymphatic infection is an early occurrence in carcinoma of the 
clitoris and vulva. A case of primary carcinoma of the clitoris in a 
woman sixty years of age came under the writer's observation six 
months from the time the tumor was discovered. Both greater labia 
were involved, and very extensive regional infection had taken place in 
both groins. In this case an oval flap was made by carrying a curvec 




Fig. 251.— Carcinoma of the labium majus (after 
Winckel). The tumor is incised vertically, showing the 
appearance of its interior. The surface is nodulated, 
and on one side is a fringe of hair derived from the 
lesser labium. 



CARCINOMA. 367 

incision the whole length of Poupart's ligament on both sides, and then 
across the lower border of the mons veneris. This flap was reflected 
in an upward direction to a point where the femoral vessels pass under- 
neath Poupart's ligament. An incision was then made downward to 
the apex of Scarpa's triangle on both sides. After reflection of the 
triangular flaps the whole chain of lymphatics was dissected out, being 
later removed with the mass containing the primary tumor and both 



Fig. 252. — Cancerous transformation of the epithelium of the labium majus (after Boyce) : a, normal epithe- 
lium ; b, warty condition; c, malignant change. (Obj. 7 inch, without eye-piece.) 

the greater labia in one piece. The hemorrhage was controlled by 
compression and by hemostatic forceps during the operation. The 
excision had to be carried to the margin of the meatus and to the lesser 
labia on the sides. The oval flap was then drawn downward and 
stitched to the upper margin of the meatus, and the wounds caused by 
excision of the labia were closed by stitching the lesser labia to the 
skin. The remaining parts of the wounds were closed in the usual 
manner. Primary healing of all the wounds on the right side took 
place ; a slight suppuration interfered with the healing of the wound 
below Poupart's ligament on the opposite side. The patient left the 
hospital three weeks after the operation, and three months later was 
reported as being free from recurrence. 

The only effective treatment of carcinoma of the external genital 
organs of the female is free excision. Large defects can be covered by 
sliding of the skin, and very large wounds heal in the most satisfactory 



3 68 



PATHOLOGY AND TREATMENT OF TUMORS. 



manner. If the disease has resulted in infection of the inguinal glands 
all the glands should be removed with the primary tumor in one con 
tinuous mass. This removal can be effected by extending the incisioi 
just below Poupart's ligament as far as the anterior superior spinou, 
process, and joining it by a vertical incision extending from the femora 
canal to the apex of Scarpa's triangle. 

Bye. — Malignant tumors in the interior of the eye are sarcomata 
The conjunctiva in rare instances is the seat of carcinoma. The tumo 
ulcerates early, and generally comes under the observation of the sur 
geon before extensive local or regional infection has occurred. Perfor 
ation of the eyeball takes place at the junction of the cornea and tht 
sclerotic, as resistance to cell-invasion here is less than in the sclerotic 
or the cornea. Regional infection takes place through the pre-auriculai 
and submaxillary lymphatics. The diagnosis should always be con- 
firmed by examination of sections of the tumor under the microscope 

as a positive diagnosis justifies 
the only radical treatment ir 
such cases — enucleation, with 
clearing out of all the orbital 
contents. 

Bladder. — Primary carci- 
noma of the bladder is a rare 
affection. It is more common 
in men than in women. It oc- 
curs as a sessile, indurated, ul- 
cerating tumor or as a papillary 
growth. The latter form oc- 
curs often as a transformation 
of a benign papilloma into a car- 
cinoma. 

Occasionally the urethra is 
the starting-point (Fig. 253). If 
in the female the urethra is 
primarily affected, the radical 
operation should be preceded 
by the formation of a supra- 
pubic fistula. After this has 
been established the entire 
urethra and the base of the 




Fig. 253.— Primary carcinoma of the urethra in the female 
(after Winckel) : a, urethra ; b, fundus of bladder. 



bladder should be excised and 
the opening in the bladder be closed permanently. This operation has 
been performed successfully by Pawlik and Oviatt. 



CARCINOMA. 369 

Carcinoma of the bladder frequently selects that part of the bladder- 
wall corresponding to the insertion of the ureters. Secondary carci- 
noma of the bladder from extension of the tumor from the prostate 
invades the base of the bladder; after the growth has reached the 
vesical mucous membrane it becomes diffuse, often blocking the orifice 
of the urethra with masses of tumor-tissue. After ulceration has set in 
shreds of carcinomatous tissue are often voided with the urine. The 
ulceration usually extends in the course of time over the entire surface 
of the tumor (Fig. 254). 




Fig. 254. — Papillary carcinoma of the anterior wall of the bladder in the female (after Winckel) : a, papillary 
carcinoma ; b, orifices of ureters ; c, urethra. 

The most prominent symptoms of carcinoma of the bladder are 
hemorrhage, frequent desire to urinate, and great pain after evacuation 
of the bladder. Microscopical examination of fragments of tissue 
voided with the urine or removed in the eye of the catheter will often 
prove of great value in making a positive diagnosis. In women an 
incision through the vesico-vaginal septum, and in men a suprapubic 
cystotomy, will enable the surgeon to make a positive diagnosis, and 
will also afford relief by establishing a permanent fistula. If the car- 
cinoma is superficial, removal after opening the bladder should be 
attempted. If the tumor involves the anterior wall or fundus of the 
bladder, the indication is for a radical operation by excision of the entire 
thickness of the bladder-wall beyond the limits of the tumor through 
an abdominal incision. If the carcinoma is so situated that the bladder 
end of one ureter has to be removed, the resected end should be 
implanted into a slit of the bladder, as advised by Van Hook, before 
the opening in the bladder is closed by suturing. 
u 



37° PATHOLOGY AND TREATMENT OF TUMORS. 

In all these operations the bladder should be drained either b; 
the use of a retaining catheter or through a separate opening. Scraping 
out of a carcinoma through either a suprapubic or a vaginal incisioi 
should not be considered even in the light of a palliative operation 
All that can be done in a case of inoperable carcinoma of the bladde 
is to establish a permanent fistula to relieve the vesical tenesmus and t< 
prevent retention of urine by closure of the urethral opening by thi 
tumor or by blood-clots. 

Kidney. — The kidney is more frequently the seat of sarcoma thar 
of carcinoma. Carcinoma of the kidney is of the tubular variety 
In a delicate, very vascular stroma the columnar epithelial cells an 
arranged in the form of tubules. According to the degree of develop- 



d -.v.v.v -'•>..;■ ,;«:#'■ ->*\ 

Aft-' . ' ' '- ' 7 *>- - ! '* » % fe.- -V 7' »> vV» 'i ■.?.■?»: -n' - 



?>«.«<, •'■■^->r^«ji.: ..jar -\r •. ^ 



Ew - h. »' .■.„»' 2y 




'»*%•■• ■■--■ " o • " * • * ■ * '• -.& °- *'A ' : * * ■ • V *»- - o 
• :•»•■ ~ ■■;'} > »*•■; V» 

Fir,.2 55 .-Displaced tissue from the suprarenal capsule in the kidneys; X 5oo(after Karg and Schraorl) 
The lower part of the picture is occupied by normal kidney-tissue (a), in which a glomerulus and transverselj 
cut uriniferous tubules can be seen ; the upper part is occupied by typical tissue from the suprarenal capsuh 
(/'), which is imbedded in the kidney-tissue. 

ment of the stroma the tumor is either hard or soft, of slow or of rapic 
growth. In exceptional cases the tumor, instead of springing from e 
matrix of embryonic cells representing kidney-tissue, originates from £ 
displaced matrix of epithelial cells derived from the suprarenal capsule 
Such displaced groups of epithelial cells (Fig. 255) are found in the 
vicinity of the kidney, in the capsule, or in the parenchyma of the 
kidney itself (Klebs). Grawitz has shown that tumors originating frorr 



CARCINOMA. 



37 1 



such a matrix represent to perfection, histologically as well as clinically, 
similar tumors of the suprarenal capsule. The tumor gradually dis- 
places the parenchyma of the kidney, and when the pelvis and the 
ureter are reached it produces obstruction to the flow of urine secreted 
by the intact part of the kidney. Eventually the tumor may perforate 
the capsule of the kidney and extend to the adjacent organs. Lymphatic 
infection takes place at a comparatively late stage. If the tumor is 
large, it may produce intestinal obstruction by extending to the colon 
or by pressure. Hematuria is a frequent symptom after the tumor has 
invaded the pelvis of the kidney. 

During life it would be, of course, impossible to distinguish a carci- 
noma from a sarcoma. Advanced age and a nodular tumor would lead 
us to suspect carcinoma. James Israel discovered by palpation a car- 
cinoma of the kidney not larger than a cherry, removed the kidney, 
and the specimen confirmed the diagnosis. The average surgeon would 




Fig. 256. — Topography of the renal region (after Esmarch) : life, trapezius muscle; Mid, latissimus 
dorsi ; Sp, sacro-lumbalis ; Ql, quadratus lumborum ; Of, external oblique ; Oi, internal oblique ; Tr t trans- 
versalis ; Fid, lumbo-dorsal fascia ; R, kidney ; C, descending colon. 

have difficulty in detecting a tumor the size of a walnut, and conse- 
quently it is not very probable that another such early diagnosis will 
soon be recorded. If a diagnosis of the probable existence of a malig- 
nant tumor of the kidney can be made, it is the duty of the surgeon to 
make careful search concerning the condition of the opposite organ, 
and if this is satisfactory a radical operation is indicated if the disease 
has not extended beyond the capsule of the kidney. Partial removal 
of the kidney for malignant disease is not permissible. 

Nephrectomy for Carcinoma of the Kidney. — The location of the 
kidney and its relations to the parts concerned in lumbar nephrectomy 



373 PATHOLOGY AND TREATMENT OF TUMORS. 

are shown in Figure 256. An accurate knowledge of the topographica 
anatomy of the renal region is an essential prerequisite in the perform 
ance of lumbar nephrectomy. A carcinomatous tumor of the kidney 
too large for the lumbar operation has in all probability reached thi 
inoperable stage. The lumbar operation is therefore the one that wil 
usually be selected to remove a carcinomatous kidney. The operatior 
of nephrectomy was devised and performed in 1871 by Simon. Th< 
incision named after him was in reality planned by his pupil, Dr. Hotz 
now of Chicago. One of two incisions is usually selected for the remova 
of the kidney through the lumbar region. Simon's incision, which give; 
the best access to the hilus of the kidney, is commenced over the eleventl 
rib, at the outer margin of the sacro-lumbalis muscle, and is extendec 
in a downward direction to a point halfway between the last rib anc 
the crest of the ilium. If more room is needed, the incision can be 
extended farther down. Konig's incision, which affords the most room 
extends from the twelfth rib, at the margin of the sacro-lumbalis muscle 
directly down to near the crest of the ilium ; it is then carried in a 
curve in the direction of the umbilicus to the outer margin of the rectus 
muscle. To enlarge the space between the last rib and the crest of the 




Fig. 257.— Position of patient and location of incision for lumbar nephrectomy according to Simon'; 

method. 

ilium a firm round cushion should be placed between the chest anc 
the pelvis on the opposite side, and the patient is placed on that side 
(Fig. 257). The different muscular layers are divided separately, and all 
hemorrhage is carefully arrested before the fatty capsule of the kidney 
is opened. When the kidney has been reached the upper half is first 
separated with the index finger ; then the kidney is seized with three 
fingers, drawn forward, and carefully isolated all around ; when the 
hilus is reached the ureter and vessels are exposed by blunt dissection ; 
all these structures are ligated en masse, and the kidney is separated by 
a cut at a safe distance from the ligature, after which ureter and vessels 
are ligated separately. Iodoform-gauze drainage and suturing of the 
balance of the wound complete the operation. 



CARCINOMA. 373 

We have every reason to believe that if a diagnosis of renal carci- 
noma could be made at a time before the tumor has extended beyond 
the capsule and before it has given rise to regional infection, a nephrec- 
tomy would yield better results than most of the operations for carci- 
noma in other localities. Under such circumstances the removal of all 
carcinomatous tissue by a nephrectomy would be assured. 



XVII. FIBROMA. 



Fibroma is a representative mesoblastic tumor. Connective tissue 
which is found in all parts and organs of the body, is its prototype 
We shall include in this class of tumors also the benign endothelial 
tumors, which have been described as endothelioma because the con- 
nective tissue and endothelial cells have a common embryonic origin 
Histological investigations have shown that in the connective tissue 
may be formed, independently of pre-existing blood-vessels, vasculai 
spaces lined with endothelial cells derived from connective tissue ; anc 
it is well known that during the cicatrization of blood-vessels aftei 
ligature and during plastic inflammation of serous surfaces endothelial 
cells are converted into permanent connective tissue. Fibroma imitates 
the normal connective tissue in the arrangement of its fibres. If the 
tumor is soft, the elastic fibres and connective-tissue corpuscles are 
arranged loosely and the cells are separated from one another by ar 
abundance of intercellular substance (Fig. .,,,. 

258). In hard fibromata the areolar struc- MM 

ture is lost, and the tumor presents to the 





Fig. 258.— Subcutaneous areolar tissue (after Piersol) : c, c, 
some of the connective-tissue corpuscles ; w, migratory cells ; 
v, plasma-cells ; e, elastic fibres. 



Fig. 259. — White fibrous tissue; on' 
end of the bundle has been teased ti 
display the component fibrillae (afte 
Piersol). 



eye and to touch the appearance of firm white fibrous tissue in whicl 
the fibrillae form bundles that run parallel, but more frequently inter 
lace, forming coarser or finer meshworks (Fig. 259). 

Fibromata occur in every part of the body supplied with connective 
tissue and blood-vessels. 

374 



FIBROMA. 375 

Definition. — A fibroma is a tumor composed of mature fibrous 
tissue derived from a matrix of fibroblasts. This definition excludes 
from this class of tumors all swellings of infective origin and all benign 
tumors in which the predominating histological elements are not con- 
nective-tissue fibres, but epithelial cells. Virchow included elephantiasis 
and molluscum fibrosum among the fibrous tumors. We exclude these 
affections because their infective origin has been demonstrated satisfac- 
torily. A great deal of confusion has been caused by some pathologists 
who continue to describe a papilloma as a fibroma. In papilloma the 
epithelial cells compose the essential part of the tumor, the tumor develops 
from a matrix of epithelial cells, and the fibrous central part is fur- 
nished by pre-existing connective tissue which, under the stimulus fur- 
nished by the proliferating epithelial cells, undergoes hypertrophic changes. 
We shall exclude from fibroma those tumors of the skin and the 
mucous membranes that have an epithelial origin and in which the epi- 
thelial cells take an active part in the growth of the tumor. These 
tumors have been described in a previous section of this work as 
papillomata. The connective tissue is the tissue chiefly predisposed to 
inflammation, and the frequency with which infections of all kinds occur 
in the connective tissue makes it often exceedingly difficult to distin- 
guish practically between an infective swelling and a fibroma. It is for 
this reason that the adjective mature has been used in this definition. 
Connective-tissue corpuscles in inflammatory products do not reach 
the same degree of maturity as in fibroma, even if the inflammatory 
process is ever so chronic. Fibro-sarcomata, which by Paget and others 
have been described as fibroid tumors with a tendency to recurrence, 
are composed of connective tissue which has nearly, but not quite, 
reached maturity. 

" Fibroid," " desmoid," " corps fibrcux," are synonyms which even 
at the present time are occasionally used in place of fibroma. 

Histogenesis and Histology. — The matrix of a fibroma is a group 
of congenital fibroblasts which in the embryo were set aside, failed to 
reach maturity, and remained in the connective tissue in a latent condition 
until, under the influence of local or general causes, they were placed in 
a condition to assert their intrinsic capacity to proliferate. If we imagine 
a number of embryonic connective-tissue cells arrested in their develop- 
ment and unutilized in the embryo, remaining in their primitive condition 
awaiting favorable conditions for their growth and reproduction, we can 
readily understand how in later life they would result in the production 
of tissue of a character differing from, although similar in structure to, 
the surrounding tissues (see Fig. 2, p. 28). Arrest of differentiation 
would affect the intercellular substance as well as the cells. From 



37° 



PATHOLOGY AND TREATMENT OF TUMORS. 



an embryological standpoint .1 fibroma is never a heterologous or a 
heterotopic tumor, as connective tissue is (bund in .ill parts and 
organs of the body. A matrix of fibroblasts undoubtedly forms 
frequently in scars following wounds and injuries of .ill kinds and in 
the healing process after the subsidence oi inflammatory affections, 
Keloid and other fibroid tumors of scars must have such an origin. 
A fibroma is always encapsulated, and can readily be enucleated. 
It it is located underneath a mucous membrane, the tumor-tissue fre- 
quently becomes cedematOUS. On section the surface shows a nunibei 
ot bands and bundles ot connective tissue interlacing in all directions 

without any definite arrangement, The cut 
??&*i§A. . . surface often shows concentric arrangement 



c iA 



lik 01 the connective tissue in different parts 01 

S the tumor, as though the tumor had been 



5&4U 



growing hom different centres. Billroth has 

shown that the centre of these concentric 

yi>-'. masses corresponds with the location ot a 

blood-vessel, The firmness ot the tumor 

Fig .«o,-H«dfibrwn» from fascia rj epe nds on the amount o( intercellular sub- 
01 rib (after Lttcke), ' 

^{awcc and the degree oi compactness of the 

tumor-tissue. In the hard variety the tumor is almost as firm to the 



i« 















/T\ ' ' 



Fio. s6i,— Fibrous tumor from the antrum of Highmore; > 430 (after D, J, Hamtlton) : a, fusiform nucleus; 
,'•, youngei nucleus of nn oval shape ; ,-, isolated fibroblast, 

touch as cartilage, the intercellular substance is very scanty, and the 

fibrillar are compactly arranged in wavy bundles or the fibres have a 



FIBROMA. 



377 



concentric arrangement as shown in Figure 260. Sections under the 
microscope show that the wavy bundles of white fibrous tissue interlace 
and surround blood-vessels. On each bundle lies an oval or fusiform 
connective-tissue nucleus, as on any other fibrous tissue (Fig. 261). 
The younger parts of the tumor show young connective-tissue cells 
of round or oval shape. 

The firmness and the histological structure of the tumor are not 
affected by the amount or the character of the connective tissue in 
which the tumor is developed. A fibroma in firm fascia may be soft, 
while a tumor in a soft vascular organ may be very dense. Fibroma 
in the soft parenchyma of the kidney may be very firm and be scantily 




Fig. 262. — Fibroma of the kidney; X 38 (after Karg and Schmorl). The renal tissue (a), which contains 
intact uriniferous tubules and glomeruli, is sharply separated from the tumor (£), which is composed exclu- 
sively of vascular fibrillated tissue. The bundles of fibrous tissue interlace in all possible directions, and 
include moderately numerous nuclei, which, according to the direction of the section, appear round or spindle- 
shaped. 

supplied with blood-vessels, although surrounded on all sides by an 
exceedingly vascular tissue (Fig. 262). In typical fibroma the vessels 
are small and scanty. In a special form of fibroma — vascular spaces, 
containing venous blood, that appear anatomically as a transition form 
between angioma and fibroma — the atypical vascularization of the 
tumor reaches the highest degree. Rindfieisch classifies this rare form 
of cavernous fibroma with the fibromata. Nothing is known regarding 
the existence of lymphatics in fibroma, but it is probable that they are 
present in the soft variety. Nerves are probably not present in fibroma, 



378 



PATHOLOGY AND TREATMENT OF TUMORS. 



but if present, they are pre-existing nerves from the sheath of which 
the tumor has developed. In fibroma of the uterus muscle-fibres are 
so constantly found that Virchow classified fibrous tumors of the uterus 
with the myomata. 

Retrograde Metamorphoses. — One of the frequent retrograde 
changes found in fibroma is myxomatous degeneration, due, in part at 




Fig. 263. — Myxomatous fibrous tumor of the deep fascia of the neck ; X 45° (after D. J. Hamilton). 

least, to cedema of the intercellular spaces (Fig. 263). The tumor 
undergoing this change becomes softer, and in the course of time there 

may form cysts with mucous or serous con- 
tents. This form of degeneration is observed 
very frequently in submucous fibroma. In 
cystic myofibroma of the uterus there form 
cysts, often of enormous size, which it is im- 
possible sometimes to distinguish from ovarian 
cysts. 

Calcareous degeneration occurs in one of 
two ways : the tumor is either coated with 
a thin, rough, nodulated layer of a chalky 
substance, or a similar substance is deposited 
more abundantly throughout the tumor (Fig. 
264). Calcification is preceded by coagulation- 
necrosis, and the place occupied by the tumor- 
tissue is taken by the earthy salts. Further 
growth of the tumor in parts which have 
undergone calcification is arrested. 

Colloid degeneration does not occur in 
fibroma, as Mr. Symmonds has shown that it 
never takes place in the absence of epithelial cells. Fatty degeneration 




Fig. 264. — Calcareous deposit 
in a fibrous uterine tumor (after 
Dusseau). 



FIBROMA. 



379 



is not as constantly found in fibroma as in epithelial tumors, but occa- 
sionally it not only takes place, but it may destroy large portions of 
the tumor. 

The tumor when exposed to external irritation is subject to ulcer- 
ation. Infection and suppuration may occur without exposure of the 

tissue of the tumor to direct 
infection by ulceration or in- 
jury. Gangrene may occur if 
in a pedunculated tumor the 
pedicle is twisted or the prin- 
cipal artery becomes blocked 
by a thrombus. Transforma- 
tion of the tumor-tissue into a 
higher type is occasionally ob- 
served in fibroma. Ossification 
has been seen most frequently 
in fibrous tumors attached to 
bone (Fig. 265). It is difficult 
to decide in such cases whether 
the new bone is produced by 
transformation of fibrous tissue, 
or whether — what seems more 
probable — it is produced by 
displaced osteoblasts. 
Etiology. — Fibroma alone or in combination with other tumors — 
lipoma, angioma, adenoma — appears sometimes as a congenital tumor. 
Old age predisposes to epithelial tumors, while the aptitude for fibroma 
is lessened after the age of from thirty-five to forty years. The production 
of fibroma of the lobe of the ear by the wearing of ear-rings, of keloids 
in scars, and of desmoids in the abdominal wall of childbearing women, 
would indicate that trauma and irritation are potent factors in the etiology 
of fibroma. Virchow describes and recognizes an hereditary fibromatous 
disposition, and he alludes to an instance of the occurrence of multiple 
subcutaneous fibromata in members of the same family in three con- 
secutive generations. 

Symptoms and Diagnosis. — The growth of a fibroma is always 
slow. A simple, uncomplicated fibroma attains a certain limited size 
and then remains stationary. The large cystic fibroids described in 
some of the older text-books were sarcomata, as it is often stated that 
the tumor reached the size of a child's head in a year or less. Fibroma 
never pursues such a rapid course. Uterine myofibromata grow more 
rapidly than simple fibroids, are more vascular, and the muscular fibres 




Fig. 265.- 



-Ossification in a periosteal fibroma of the 
lower jaw (after Liicke). 



380 PATHOLOGY AND TREATMENT OF TUMORS. 

constitute the most important part of the tumor-tissue. The tumor is 
smooth and is always well encapsulated, hence movable unless restrained 
by adjoining firm resisting tissues. A fibroma of the breast can be moved 
among the tissues between two fingers without moving the gland — an 
important point in the differential diagnosis between fibroma and carci- 
noma. The tumor displaces, but does not infiltrate, the adjoining tissues. 
The pressure of a periosteal fibroma frequently results in great displace- 
ment of the bone by bending and by pressure-atrophy. If the tumor 
occupies a cavity, it may interfere with important functions. A fibroma 
of the nasal cavity interferes with respiration, and, when it reaches the 
pharynx, with speech and deglutition. A fibroma of the uterus, if 
submucous, causes hemorrhage ; if subserous, it may by its size affect 
important functions. Pain and tenderness are absent unless the tumor 
is intimately connected with a sensitive nerve or unless it has become 
complicated by infection and inflammation. In fibroma ulceration is 
less likely to take place than in papilloma, because the tumor is covered 
at least by skin or by mucous membrane. If the skin or the mucous 
membrane becomes atrophied from pressure, ulceration is likely to 
ensue, commencing in that part of the surface in which nutrition has 
become most impaired. 

In differentiating a fibroma from a papilloma it is important to trace 
the tumor by the aid of its clinical history and by a careful examina- 
tion as to its origin in the mesoblastic tissues. A papilloma of the 
skin commences on the surface as an increase in the thickness of the 
epithelial layer of the skin; the papillary projections develop in. conse- 
quence of an accompanying hyperplasia of the underlying pre-existing 
connective tissue. In fibroma of the skin the tumor starts in the con- 
nective tissue underneath the layer of epithelial cells, and pushes this 
layer before it. A fibroma of the skin is therefore less liable to become 
pedunculated than is a papilloma. A fibroma only becomes peduncu- 
lated if the skin over it is yielding, and after the tumor has attained at 
least the size of a pea or a cherry. In pedunculated fibroma the skin 
which covers the tumor becomes atrophic, smooth, and glassy, while in 
papilloma the epithelial structures increase with the size of the tumor. 
In deep-seated fibroma the diagnosis between it and sarcoma is deter- 
mined by the clinical history and, if need be, by the removal of a frag- 
ment of tissue with a harpoon for microscopical examination. In cystic 
fibroma the use of the exploratory needle will often determine the cha- 
racter of the tumor. 

Prognosis.— Fibroma may at any time undergo transition into a 
sarcoma. As Virchow says, " A fibroma only needs an increase in the 
size of its cells and a diminution of the cement-substance to change it 



FIBROMA. 381 

into a sarcoma." The hard variety is less apt to undergo this change 
than the soft, and particularly the pigmented, form. That irritation and 
incomplete removal should hasten, if not determine, the transforma- 
tion of a fibroma into a sarcoma no one would dispute. The young 
connective-tissue cells in the periphery of the tumor require only the 
addition of conditions which enable them to leave the parent-tumor 
and to migrate into the surrounding connective tissue to become 
sarcoma-cells. A pure fibroma does not attain large size ; hence the 
prognosis, aside from the possibility of the tumor undergoing transfor- 
mation into sarcoma, must rest on the importance of the location it 
occupies. If it involve passages essential for important functions, the 
obstruction it produces may prove a source of danger. Fibroma of 
the respiratory and urinary passages affords an illustration in point. A 
submucous fibroma of the uterus may become the cause of debilitating 
and even fatal hemorrhages. A large interstitial fibroma of the uterus 
may destroy life by the size of the tumor interfering with important 
functions of the abdominal oreans. 

Treatment. — Operative treatment is indicated in fibroma in all cases 
in which the tumor is accessible, as by the removal of the tumor the 
patient is protected against a frequent cause of sarcoma. In uterine 
fibroma an exception must be made to this rule, as the danger attending 
the operation outweighs the risk of a possible transition of the tumor 
into a sarcoma. In fibroma of the uterus other indications must 
decide the necessity of operation. Fibromata should be removed by 
enucleation. Excision is necessary if the tumor has ulcerated on the 
surface or if the interior of the tumor has become infected and the 
resulting inflammation has produced adhesions between its capsule 
and the adjacent tissues. 

Topography. 
Skin. — Fibroma of the skin occurs most frequently about the face, 
neck, shoulders, chest, and abdomen. It is of very slow growth, and 
seldom exceeds in size a pecan-nut. It appears first as a swelling in 
the connective tissue of the skin, which swelling projects toward the 
surface, becoming more and more prominent until the skin at its base 
becomes contracted and by the weight of the tumor elongated, resulting 
in the formation of a pedicle. In the course of time this pedicle 
becomes elongated and very slender. It contains in its centre the 
principal artery of the tumor, which artery sometimes, in consequence 
of an injury or of textural changes, becomes thrombosed — an accident 
which results in gangrene of the tumor and a spontaneous cure. The 
skin over the tumor atrophies, is thin and shining, and is usually thrown 



382 PATHOLOGY AND TREATMENT OF TUMORS. 

into longitudinal folds. The tumor is soft, and under the microscope 
shows interlacing fibres with an abundance of intercellular cement- 
substance. 

The diagnosis can be made without difficulty, as in papilloma, which 
is most frequently confounded with fibroma, the epiblastic part of the 
tumor predominates, and instead of a smooth surface presents a warty 
appearance. If the tumor has become pedunculated, it is connected 
with the body only by a cylinder of skin, which can be clipped with 
scissors on a level with the skin, and the resulting wound can be sealed 
with a cotton-collodion crust. If the tumor is sessile, the skin over it 
or at its base is incised sufficiently to permit the removal of the tumor 
by enucleation. 

Mole. — A mole is a flat congenital fibroma of the skin. It is caused 
by fibroblasts in excess in the connective-tissue portion of the skin. 
Moles are usually pigmented, and giant growth is manifested by exces- 
sive growth of the appendages of the affected part of the skin, the 
hair, and the glands. Moles vary in size from that of a pin's head 
to that of the palm of the hand or even larger. The increase in size 
after birth reaches its maximum during childhood and up to the age 
of puberty, when the tumor generally becomes stationary. A mole 
is exceedingly prone to undergo transition into a carcinoma or a sar- 
coma, and for this reason should be removed if the area involved is not 
too extensive. A carcinoma or a sarcoma starting in a mole is usually 
pigmented ; the resulting malignant tumor is either a melano-carcinoma 
or a melano-sarcoma — both of them exceedingly malignant growths, and 
very prone to early diffuse regional infection and general dissemination. 
Keloid. — Another variety of fibroma in the skin is the fibrous tumor 
which starts in scar-tissue following a wound, the healing of a burn, or 
other surface lesions, particularly tubercular ulcers. Alibert in 18 14 
was the first to describe this fibrous tumor, and from its resemblance 
to carcinoma he called it " keloid." Keloid resembles clinically some of 
the granulomata, and under the microscope it is a compromise between 
a fibroma and a sarcoma. Its frequent occurrence in tubercular scars and 
in minute scars resulting from small punctured wounds has led the 
writer to suspect that it might represent a particular form of tuber- 
cular inflammation. We are, however, not in a position to prove its 
tubercular origin and nature, and its clinical behavior would certainly 
tend to negative the idea that it is a form of sarcoma. For the present 
we must include it among the fibromata, although strongly inclined to 
believe that before long it will have to be classified with the infective 
swellings. The colored race is peculiarly predisposed to keloid. The 
sting of an insect, the prick of a needle, or a small abrasion frequently 



FIBROMA. 



383 



acts as the exciting cause. The wearing of ear-rings is also a frequent 
cause (Fig. 266). 






1111 






i^&Jl 




Fig. 266. — Keloid in the lobule of the pinna, associated with an ear-ring puncture (after Sutton). 



same 
elude 



Keloid sometimes affects different parts of the body at the 
time, but always develops in a scar, which may be so small as to 
detection (Fig. 267). The tumor slowly „ „ 

increases in size up to a certain point, and 
after having remained stationary for from 
ten to twenty years may slowly disappear 
— one of the strongest proofs that it is not 
a true tumor. The keloid tissue is charac- 
terized by its great vascularity as compared 
with other fibromatous tumors and by the 
existence of numerous connective-tissue 
spaces lined with endothelial cells. The 
inflammatory part of a keloid is shown by 
the numerous leucocytes in the perivascular 
spaces. From the structure of a keloid it 
would be reasonable to assume that occa- 
sionally it is transformed into a sarcoma. 
The benign clinical aspects of a keloid 
render it easy to distinguish between it and 
a malignant tumor of the scar-tissue. 

The treatment of keloid is extremely unsatisfactory. External appli 




Fig. 267. — Multiple keloid in a 
woman (after Taylor). 



otored 



384 PATHOLOGY AND TREATMENT OF TUMORS. 

cations and compression are useless. Recurrence even after thorougr 
extirpation is common. The only treatment is by thorough excision 
The incisions should include a zone of apparently healthy tissue at leasi 
a few lines in width. The scar following the operation should be pro- 
tected carefully for a long time. 

Mucous Surfaces. — Fibroma of the mucous surfaces resembles 
that of the skin in every respect except that the surface of the tumoi 
is covered by mucous membrane instead of by skin, and that the tumoi 
in this locality is more prone to oedema. Many of the polypoid growths 
in mucous channels are cedematous fibromata. If pendulous, they 
should be removed with the wire ecraseur; if sessile, by excision 01 
by enucleation. 

Subcutaneous Connective Tissue. — Two kinds of fibroma, clinically 
distinct, are met with in the subcutaneous connective tissue — the pain- 
ful tubercle and the soft multiple fibroma of Recklinghausen. 

Painful Subcutaneous Tubercle. — This is a little hard tumor, nol 
larger than a pea, noted for its painfullness, in the subcutaneous tissue, 
This tumor was first described by A. Petit, Cheselden, and Camper. 
The best description was given in 18 12 by Mr. Wm. Wood. These 
tubercles are most frequent in the extremities, especially the lower 
They are more frequent in women than in men, they rarely occur 
before adult life, and they are seldom multiple. Examined under the 
microscope, they are seen to be composed of dense fibrous tissue, with 
filaments laid inseparably close together in the fasciculi and compactly 
interwoven. The young cells in the periphery of the tumor contain 
large nuclei. The pain and tenderness appear either contemporane- 
ously with the tumor or after the tumor has reached a certain size 
The pain, which is usually paroxysmal, but which can always be pro- 
voked by pressure, is sometimes attended by muscular spasms. Vel- 
peau regarded these tumors as neuromata. Dupuytren, who made 
several very careful dissections, was never able to trace their connectior. 
with nerve-fibres. Other surgeons have succeeded in finding the nerve- 
filaments with which these tumors are connected. In one case the 
writer could trace the nerve from the capsule of the tumor on botr 
sides. The nerve was no larger than a fine silk ligature. There car 
be no doubt that these tumors are connected with sensitive nerve-fila- 
ments. Their removal by excision is often followed by recurrence 
Successful removals of recurrent painful tubercles are reported by Sii 
James Paget and by Mr. Lawson Tait. 

Multiple Subcutaneous Fibroma. — The true pathology of multipk 
fibrous tumors of the subcutaneous tissue was pointed out in 1882 b) 
Recklinghausen. He ascertained that these tumors are invariabl) 



FIBROMA. 



Plate 8. 








f 




i. Keloid of external ear (after Klebs) : a, dense fibrous cutis tissue with wide juice-canals, endothelial 
lining, and hyaline ground substance ; /■, fibrillated connective tissue with abundance of cells, with large vessels, 

F"~ : — — — -' — - --- — : — — ; — '■ i.ds ; c, attenuated epidermis, the papillae having 

i ^^hh^^^^^^^^^^^^^^^^^^^^^^mb <, fibromata. 



FII5ROMA. 



Plate 9. 




Multiple neuro-fibroma, early stage (after Klubs) : a, outer, b, inner nerve-sheath with endothelial hollow 
spaces; c, nerve-substance. (Zeiss, E. 2.j 



FIBROMA. 385 

connected with the sheaths of terminal nerves. They are sometimes 
congenital, but they usually develop after puberty. In number they 
vary from a few to more than a thousand. In the case of Michael 
Lawler, described in Smith's monograph, they were estimated at least 
at two thousand. This affection was formerly known as " molluscum 
fibrosum " (PL 8, Fig. 2). In size these tumors vary from that of a 
hemp-seed to that of a filbert. In the course of time some of the 
tumors become pendulous. Histologically, these tumors are composed 
largely of fibrous tissue around and between bundles of nerve-fibres. 
On Plate 9 a number of nerve-bundles can be seen cut transversely. 
The connective tissue between the nerve-bundles has been changed 
but little ; perhaps the connective-tissue spaces are somewhat dilated. 
Small round groups of nuclei stained blue with hematoxylin show 
the transverse cuts of blood-vessels. The connective tissue is greatly 
increased in the nerve-sheaths. The nuclei of the cells are oblong, 
oval, crowded closely together in the larger bundle (3), while the sheath 
of the smaller bundle contains fewer nuclei. The nerve-sheath can in 
many places be distinguished into an outer and an inner (a and b), as 
there can be seen between the fibres of the sheaths, arranged trans- 
versely, spaces which do not occupy in a continuous manner the entire 
periphery ; there can also be seen, on the inner surfaces of the sheath, 
spaces which at some points are quite wide, and which (at 3) show oval 
nuclei in their walls. These spaces are in contact with the nerve-fibres 
and are traversed by delicate connective-tissue threads. In the longi- 
tudinal section (at 2) they can be seen in the same form. During the 
growth of the tumor the interstitial connective tissue proliferates and 
the nerve-bundles are separated more widely. Clinically these tumors 
form a contrast with the painful subcutaneous tubercle by the absence 
of pain and tenderness and by their multiplicity. Owing to the multi- 
plicity of the tumors operative treatment is contraindicated. Should 
any of the tumors manifest malignant qualities, early and thorough 
excision is urgently indicated. 

Abdominal Wall. — A peculiar form of deep-seated fibroma of the 
abdominal wall was first described by Nelaton. In his cases the tumors 
either occupied the iliac fossa or were located near the crest of the 
ilium. These places are the favorite localities, but the sheath of the 
rectus muscle is also not infrequently the starting-point of fibroma 
of the abdominal wall. The primary starting-point is most frequently 
near the peritoneum, so that the tumor projects at the same time 
into the peritoneal cavity, pushing the peritoneum before it while it 
becomes prominent on the surface. It is most frequently met with in 
women after delivery. Among 42 cases collected by Guerrien there 



3 86 



PATHOLOGY AND TREATMENT OF TUMORS. 



were 39 women and only 3 men. Of the 4 cases which have come 
under the writer's observation, all were women, and in each of 
them the tumor appeared soon after childbed. As compared with 
other tumors of the abdominal wall, fibroma occurs most frequently. 
In 70 cases collected by Sanger, 60 were fibromata. Trauma 
appears to be the most important determining cause. Great con- 
fusion has existed in regard to the proper classification of these 







Fig. 268.— Desmoid fibroma of the abdominal wall ; X 330, reduced one-third (Surgical Clinic, Rush 
Medical College, Chicago) : a, tumor-tissue ; b, striated muscle-fibres in cross-section : the striae have disap- 
peared, and the muscle is degenerating and is infiltrated with young connective-tissue cells. 

tumors. Some authors are inclined to regard them as a variety of 
facial sarcoma. Their clinical course and histological structure do not 
justify their classification with the sarcomata. They seldom recur after 
thorough extirpation, and their histological structure bears a closer 









rjKSS£ll3£**v-«~ 




Fig. 269.— Vessel in a desmoid fibroma of the abdominal wall; X 33° (Surgical Clinic, Rush Medical 
College, Chicago) : a, vessel-wall. 

resemblance to fibroma and keloid than to sarcoma. To distinguish 
them from ordinary fibroma it is well to retain the name desmoid 



FIBROMA. 



387 



a term applied by Miiller to benign connective-tissue tumors (Fig. 
26S). The tumor-tissue is composed of young connective-tissue cells 
with a scanty intercellular substance. The cells infiltrate the adjacent 
tissues besides displacing them, in this respect differing materially from 
ordinary fibroma. The walls of the new blood-vessels in the tumor 
display an intimate relation with the tumor-tissue (Fig. 269). The 
endothelial cells lining the new blood-vessels are large, and the tumor- 
tissue forms the greater part of the vessel-wall. 



gg^p^g?tjaJ:g^i: .^- . ■ ^- "^-_ 




,■'".-' "-""» ■■• -*"" *"s-^5- ^-^^ .~*z*>-, " ■ 







ss<l§^ 






Fig. 270. — Relations between vessel-wall and tumor-tissue in a desmoid fibroma of the abdominal wall ; 
X 330, reduced one-third (Surgical Clinic, Rush Medical College, Chicago) : a, junction of vessel-wall and 
tumor-tissue. 

From the histological description of a desmoid tumor as given 
above it is evident that the encapsulation of the tumor is imperfect — 
an important point to be remembered in the operative treatment of such 
tumors. Desmoid tumors increase quite rapidly in size, sometimes 
reaching from the umbilicus to the pubes and from the anterior superior 
spinous process of the ilium to the median line. In three of the writer's 
cases the peritoneum was firmly attached and had to be excised with 
the tumor. 

Enucleation of the tumor is liable to be followed by recurrence. In 
two of the writer's cases the tumor started in the iliac region, and in 
two in the sheath of the rectus muscle. All these cases recovered. 
In one of them a recurrence made necessary a second operation, after 
which complete recovery ensued. 

The diagnosis is not always easy. If the tumor projects as much 
in the direction of the abdominal cavity as externally, it might easily 
be mistaken for an intra-abdominal tumor. The tumor moves with the 
abdominal wall, but this is also the case if an abdominal tumor has 
become, attached to the parietal peritoneum anteriorly. The tumor is 



388 PATHOLOGY AND TREATMENT OF TUMORS. 

firm and can generally be outlined accurately. In the excision of ; 
desmoid tumor of the abdominal wall the surgeon must be preparec 
to resect the peritoneum, and must therefore make all the preparation: 
required for abdominal section. The removal of such a tumor result: 
in great defect of the abdominal wall, which defect must be correctec 
by suturing the peritoneum and the muscular layer separately witl 
buried catgut sutures, including at the same time all the tissues in th< 
deep sutures in order to approximate the surfaces of the wound accu 
rately, so as to prevent the subsequent formation of a ventral hernia 
As an additional safeguard it is necessary to instruct the patient to weai 
a well-fitting abdominal bandage for from six months to a year after th< 
operation. 

Nose. — Robert has shown that many of the naso-pharyngeal fibroui 
tumors start from the anterior lacerated foramen, the basilar process of 
the occipital bone, and even from the upper cervical vertebrae. Th« 
fibrous polypus of the nose grows slowly, and after it has reached £ 
certain size protrudes in the direction of the nasal outlet or project: 
into the pharynx. From pressure the nose often becomes flattened anc 
the mouth prominent, or the roof of the mouth is displaced downward 
Digital exploration of the naso-pharynx is important to determine the 
exact location, size, and attachment of the tumor. If the tumor is nol 
pedunculated sufficiently to enable its removal by torsion, its operative 
removal requires a bloody and often a dangerous preliminary operatior 
to reach its base. If the tumor is attached in front of the naso-pharynx 
the nostril is incised from within outward on the side of the septum a; 
far as the nasal process, as advised by Dieffenbach and Konig ; if this 
incision does not afford sufficient room, the nasal process is temporarily 
resected ; and if still more room is required, the upper lip is divided ir 
the median line and is dissected backward. If the base of the tumoi 
can be reached in this manner, the tumor is drawn forward with vulsel- 
lum forceps and its attachment is severed with a narrow periostea' 
elevator or with blunt-pointed scissors. All operations for the remova 
of naso-pharyngeal growths requiring a preliminary bone operatior 
should be performed under partial anesthesia, or, as the writer has beer 
in the habit of calling it, " a talking narcosis." 

Fibrous tumors of the nose and the naso-pharynx are exceedingl} 
vascular, and their removal is attended by profuse and even fatal hem- 
orrhage, notwithstanding the employment of prompt and efficienl 
hemostatic precautions. In a case operated upon before the class ir 
Rush Medical College, Chicago, in 1893, the writer took the precautior 
to make a preliminary tracheotomy. Two weeks later the operatior 
was commenced by ligating the common carotid. Kocher's temporary 



FIBROMA. 



389 



resection of the upper maxilla was then performed. The hemorrhage, 
notwithstanding compression and the use of hemostatic forceps, was 
alarming, and the patient nearly died upon the table from loss of blood. 





Fig. 271. — Resection of nasal process of the superior maxilla (after Langenbeck) : a, external incision; b, 
line of section through nasal process. 

Instead of slitting open the nostril, Langenbeck makes a curved 

lateral incision through which he 
resects the nasal process of the 
superior maxilla (Fig. 271). If the 
tumor obstructs both nasal passages, 
temporary detachment of the nose 
according to Rouge (Fig. 272) or 
Oilier (Fig. 273) will afford better 
access to the base of the tumor 
than will the unilateral incision. 





Fig. 272.- 



-Temporary detachment of the nose ac- 
cording to Rouge. 



Fig. 273. — Temporary resection of the nose accord- 
ing to Oilier. 



The bone-sections in making temporary resection of the nose 
should be made with a sharp chisel instead of with a saw. After the 
removal of the tumor the nose is replaced and the wounds are sutured 
accurately with fine silk or with silkworm gut. Bruns makes tempo- 
rary resection of the nose by displacing it laterally. The removal of 
naso-pharyngeal tumors through the hard or the soft palate has 
been practised by Manne (171 1), Dieffenbach, Hueter, and Nekton. 
Demarquay and Trelat resected through an external incision the nasal 
process of the superior maxilla and the anterior wall of the antrum of 



39° 



PATHOLOGY AND TREATMENT OF TUMORS. 



Highmore. The great deformity which followed this operation le< 
Langenbeck in 1861 to devise temporary resection of the upper maxilla 
Kocher has recently modified Langenbeck's operation. Temporan 
resection of the upper maxilla after Langenbeck and Kocher is a diffi 
cult and an exceedingly bloody operation, and should never be lighth 
undertaken. Konig lost a patient on the table from hemorrhage ii 
performing Langenbeck's operation, and the patient mentioned on pagi 
388 barely escaped the same fate, and later succumbed to the effect: 
of the excessive loss of blood, although the common carotid artery 
had been tied as a prophylactic hemostatic precaution. 

In naso-pharyngeal fibrous growths every attempt should be mad< 
to remove the tumor by less heroic measures than extirpation througl 
the hard palate or after temporary resection of the upper maxilla, b) 
the use of the wire ecraseur or the galvano-caustic sling, the forma 
operation being reserved for the most desperate cases. 

Tumors of the base of the skull which are behind the maxilla anc 
grow into the temporal fossa can be removed only after a temporary 
resection of the maxilla. 

Mammary Gland. — Most of the tumors that have been describee 
as fibroma have been cases of adenoma. If the tumor contains any 
adenomatous tissue, it is an adenoma and not a fibroma, no mattei 
how much fibrous tissue it may contain. Pure fibromata of the mam- 




Fig. 274— Fibroma of the mammary gland ; X 250 (after Perls). The fibrous tissue is swollen ; the space- 
with the nuclei appear as connective-tissue corpuscles ; a, a, remnants of gland-ducts. 



mary gland are exceedingly rare. They start in the interacinous 01 
intertubular connective tissue, grow very slowly, and never attain large 
size. Pain and tenderness are either entirely absent or, when present 
are not well marked. The fibrous tissue may surround and include 
pre-existing gland-ducts, in which event the cells become destroyed by 
pressure-atrophy, and the ducts in the course of time may become com- 
pletely obliterated (Fig. 274). 



FIBROMA. 



39* 



Differential diagnosis between fibroma of the breast and adenoma 
is impossible without the use of the microscope. Fibroma is distin- 
guished from sarcoma and carcinoma by its slow growth and by the 
mobility of the tumor in the tissues of the gland. Fibroma of the 
breast should be removed by enucleation. The recurrent fibroid tumor 
of the breast described by Paget is a spindle-celled sarcoma. 

Uterus. — Fibroma of the uterus as a purely fibroid growth is ex- 
ceedingly rare. With few exceptions the tumor contains muscle-cells, 
and has been described in the section on Myoma. 




Fig. 275. — Fibroma of both ovaries ; the right is as large as a kidney, the left larger than a child's 
head (after Winckel) : ff, surface of tumor on left side, with numerous nodules ; b, fundus of uterus ; c, sur- 
face of tumor on right side ; d, section of right ovary ; e, OS uteri ; f t surface of left ovary ; g, cut surface 
of tumor on left side. 



Ovary. — Fibromata of the ovary are so rare that Sutton regards 
them as pathological curiosities. The writer has met with two such 
cases. In one of them the tumor was recognized ten years before the 



392 



PATHOLOGY AND TREATMENT OF TUMORS. 



operation. The operation was postponed until the patient was driver 
to it by a very extensive ascites. The pedicle of the tumor was slendei 
and there were no adhesions. The tumor weighed twenty pounds, was 
very firm, and was nodulated on the surface. Sections under the micro- 
scope showed nothing but wavy bundles of fibrous tissue interlacec 
in all directions. The blood-vessels were few and small. In the sec- 
ond case the tumor was about half as large and presented a similai 
structure. The enlargement of the abdomen due to ascites in thi; 
instance also induced the patient to submit to an operation. Both 
patients recovered from the operation and remain well up to the presenl 
time, the first twenty and the second two years after operation. Ir 
both cases the peritoneum was exceedingly vascular — a conditior 
caused by its being thrashed, as it were, by the tumor, for a numbei 
of years. The writer has come to regard ascites as an important 
diagnostic evidence of movable solid tumors of the ovary. Neither of 
the tumors showed on section evidences of cystic degeneration. Occa- 
sionally both ovaries are affected at the same time (Fig. 275). 

Ascites is usually the first thing noticed by the patient, and it h 
for this condition, and not for its cause, that the patient seeks relief 
Ascites in the absence of malignant disease of the pelvic or abdominal 
viscera should remind us of fibroma of the ovary as the possible cause 
Fibroma of the ovary occurs most frequently in women between twenty 

and forty years of age. Leopolc 
mentions 1 3 cases at from five tc 
thirty years of age, and only 4 
at thirty to forty years. Ferriei 
removed a fibroma of the ovaiy 
from a woman seventy-six yean 
old. 

The differential diagnosis be- 
tween a fibroma of the ovary anc 
a desmoid cyst is difficult, and be- 
tween a fibroma and a peduncu- 
lated myofibroma of the uterus ii 
impossible, without an explora 
tory laparotomy. Removal b) 
laparotomy is a safe operation 
and if the tumor is completer) 
removed recurrence never take: 
place. 

Vulva. — Tumors are rare as compared with chronic infective swell 
ings of the vulva. Fibroma occurs less frequently than papilloma 




Fig. 276. — Papilloma of the vulva; X 25 (Surgical 
Clinic, St. Joseph's Hospital, Chicago): a, stroma of 
loose connective tissue ; £, blood-vessels ; c, epithelium; 
d, horny layer. 



FIBROMA. 



393 



is found more often upon the labium majus than upon the nymphse, and 
appears first as a soft swelling with a broad base. It is of slow growth, 
does not attain large size, and may become pendulous by elongation of 
the skin covering it. Fibroma, which can be distinguished from papil- 
loma by the smoothness and thinness of the overlying skin, is not as 
often multiple as is papilloma. Sections of a papilloma show that the 
greater part of the tumor is composed of epithelial cells attached to a 
vascular stroma (Figs. 276, 277). A vertical section of a fibroma would 
show the skin covering the tumor to be atrophied and the tumor-tissue 
to be composed exclusively of interlacing fibres or bundles of fibres 
of connective tissue. 

Fibromata of the vulva may be enucleated, or their pedicles may be 
cut, without danger of hemorrhage, as the blood-supply is scanty. 



"'VoV 



i- 



•St**'.. »*'•' ■<..".' *...•'•»» •■.,'. /V-'-fi-*.- 




Fig. 2 77 .-Periphery of tumor shown in Figure 276 (X 140): «. stroma: *, blood-vessels; c, very thick 
stratum of epithelial cells ; d, horny layer ; e, loss of substance probably caused by degeneration. 

Gums. — Formerly all tumors of the gums were included under the 
name of " epulis." Microscopical examination of different tumors has 
shown the necessity of differentiating between sarcoma, carcinoma, and 
fibroma of the gums. Fibroma of the gums appears as a bone-swelling 
covered by the mucous membrane ; the tumor grows slowly and does 
not return after thorough removal. The term " epulis " should be 
restricted to designate a fibroma originating from the gums or from the 
periodontal membrane. Local irritation caused by a decayed tooth or 
by incrustation upon the teeth is the most frequent exciting cause of 
fibroma of the gums. The tumor is seldom larger than a walnut, and 
its base is often constricted into a short pedicle. Mr. Hawkins made 
the assertion that fibroma of the gums, the fibrous epulis, grows, like 



394 



PATHOLOGY AND TREATMENT OF TUMORS. 



most of the other fibrous tumors, from the bone and periosteum and 
continuous with them. 

The radical removal of a fibroma of the gums can be effected only 
by excision of the alveolar border of the jaw. This excision can be 
done, after the extraction of one or more teeth, with the chisel or with 
a narrow metacarpal saw. In benign fibrous tumors of the alveolar 
border and the gums it is unnecessary to resect the jaw in its entirety, 
as recommended by Gross and others. 

Periosteum and Bone. — The maxillary bones are the most frequent 
seat of fibroma. The fibrous tumor of these bones is very hard, has a 




Fig. 278. — Distortion of dental arch caused by the tumor represented on Plate 10. 

smooth surface, and is covered by skin and mucous membrane. Cystic 
degeneration occasionally takes place. It is difficult to determine 
whether these tumors start from the periosteum or from the connective 
tissue of the bone. They do not infiltrate the bone to which they are 
attached, but cause pressure-atrophy and distortion of the bone. 

The tumor represented on Plate 10 (Fig. i) occurred in a man twenty 



FIBROMA. 



Plate io. 




i. Enormous fibroma of the upper maxilla. 2. Showing condition of parts immediately after excision 

of the tumor. 



FIBROMA. 395 

years of age, and was first discovered when he was ten years old. In 
1890 it was only partially removed through a small incision. Two 
years before the operation the patient consulted a prominent surgeon, 
who pronounced it a sarcoma and refused to operate. When the patient 
came under the writer's observation the tumor had become very promi- 
nent in the cavity of the mouth — so much so that deglutition and speech 
were greatly affected. The tumor was removed, through the incision 
shown on Plate 10 (Fig. 2), by enucleation, without any special diffi- 
culty. The wound healed promptly, leaving a deep depression in the 
right cheek, where the tumor had been most prominent. No recurrence 
had taken place two years after the operation. Sections of the tumor 
examined under the microscope showed the typical structure of a dense 
fibroma. 

Small fibromata of the jaw can be removed through the mouth, 
but large tumors must be enucleated through an external incision. 

Serous Surfaces. — Papillomatous and fibrous tumors of the serous 
surfaces are rare, and their structure is very similar to that of the same 
kind of tumors of the skin, except that in place of epithelial cells the 
tumors are covered by endothelial cells — in the former variety by 
numerous strata, in the latter usually by a single layer. Benign fibrous 
and endothelial tumors are found most frequently upon the peritoneum 
and upon the synovial membrane of joints. When such a tumor 
becomes pedunculated it is often detached and remains in the cavity 
as a foreign body. 

Cholesteatoma. — Closely allied to psammoma is cholesteatoma, first 
described by J. Muller. It was later described by Cruveilhier as tuincur 
pcrlee, or pearl tumor. The tumors do not exceed in size a cherry. 
They present a pearl-like metallic lustre, and they are found most fre- 
quently at the base of the brain, imbedded in the tissues of the pia 
mater. In this locality these tumors are often found so closely aggre- 
gated as to form nodulated masses an inch or more in diameter. 
Within a very delicate membrane there is found a fatty substance in 
concentric leaf-like layers. Microscopical examination of the layers 
shows that they are composed of large cells between which globules of 
fat and cholesterin-plates are seen. The pearl-like appearance of the 
tumor is due not to the cholesterin, but to the compact layers of the 
cells. The cells are derived from endothelium, and not from epithelium, 
as was formerly supposed. Cholesteatoma is found besides in the 
meninges and the ventricles of the brain, in bones, especially the petrous 
portion of the temporal and mastoid processes, in the testicle, and in the 
ovary. In the meninges of the brain cholesteatoma probably starts in 
the perivascular lymph-spaces. Rindfleisch strongly maintains that 



& 



396 PATHOLOGY AND TREATMENT OF TUMORS. 

these tumors in the meninges of the brain are of endothelial origin 
Wendt believes that in the petrous portion of the temporal bone chole 
steatoma is produced by inflammation of the middle ear resulting ir 
desquamation and accumulation of epithelial cells, but he has describee 
also genuine cholesteatoma of endothelial origin in the drum of the 
ear. In tumors of the pia mater belonging to this category this mem 
brane surrounds the tumor mass, but the space is not lined by endo- 
thelial cells. Ziegler found hair in some of these tumors, in which 
case we must assume for some of them an epithelial origin from a 
displaced tumor-matrix ; but these cases must be exceedingly rare 
Eberth found that in cholesteatoma of the pia mater the first change 
that is seen in the formation of the tumor is the appearance of proto- 
plasmic masses which surround the vessels like a sheath. In the 
sheath irregular nuclei are seen, besides giant-cells. Virchow and 
Eberth claimed that these cells were epithelial cells produced by hetero- 
plastic proliferation of the connective tissue. This view is, of course 
no longer tenable, as we have shown repeatedly that epithelial cells 
are never produced from connective tissue. Cholesteatoma never gives 
rise to metastasis, and it manifests no tendency to invade surrounding 
tissues to any extent, resembling in these respects psammoma, with 
which it is histologically and clinically so closely allied. 



XVIII. LIPOMA. 



Definition. — A lipoma is a circumscribed or diffuse tumor composed 
of fatty tissue produced from a matrix of lipoblasts. The subcutaneous 
fatty tissue is the favorite seat of lipoma. Toldt ascertained that in 
the embryo the panniculus adiposus is formed by cell-islets, the so- 
called " fat-organs," each of which has a separate and independent 
blood-supply. These islets are separated from one another by connec- 
tive tissue. Young fat-cells are called " lipoblasts." Their number and 
activity, as well as the assimilation of fat from the blood or the food, 
determine the amount of fat. Each fat-lobule has its own artery and 
capillary circulation, terminating in a common vein. The lobule there- 
fore represents an organized unity, like an acinus in the liver. Accord- 
ing to Virchow, the lipoblasts develop from fetal myxomatous tissue 
into which the mature fat-cells can revert. If the cells of any of 
these fat-forming centres should become arrested in their develop- 
ment and remain, in a quiescent state, it is easy to see how at any time, 
by their resuming active tissue-proliferation, they could give rise to a 
fatty tumor. Having become emancipated, as it were, from the organ- 




Fig. 279. — Fat-cells imbedded in subcutaneous areolar tissue (after Schiefferdecker) : /, fat-cells ; n, 
nucleus; c, connective-tissue corpuscles ; iv, migratory cells ; e, elastic fibres ; b, capillary blood-vessels. 

ism, their growth, development, and reproduction would no longer be 
controlled by the laws which regulate normal nutrition. It would be 
difficult to explain localized hyperproduction of fatty tissue in any 
other way. 

Histology. — The fat-cells in a lipoma, as in normal adipose tissue, 
represent connective-tissue cells with oily contents. The cells are 

397 



398 PATHOLOGY AND TREATMENT OF TUMORS. 

round or oval sacs ; the transparent contents are limited by a delicat 
envelope composed of cell-membrane and of an extremely thin laye 
of protoplasm. The nucleus is located on one side of the sac (Fig 
279). 

There is nothing to distinguish a fat-cell in a lipoma from a fat-eel 
in normal adipose tissue. The cells occur in groups supported anc 
held together by areolar tissue through which ramifies a rich vas 
cular network. The amount of stroma varies : in the soft lipomata i 
is very scanty, so that under the microscope it is difficult to recognizi 
it, it being almost completely overshadowed by the fat-cells. In thi 
hard lipoma the fibrous structure of the tumor is well developed an< 
the fat-cells are crowded into the large areolae of the stroma. Sonn 
lipomata are exceedingly vascular, and we then speak of a liponn 
telangiectodes. In other instances the stroma contains venous channel: 
of large size, when the tumor is called lipoma cavcrnosum. The write 
has met with such vascular lipomata most frequently in congenita 
lipoma. 

Regressive Metamorphoses. — The stroma of 'a lipoma is mor< 
prone to undergo retrogressive metamorphosis than is the parenchym; 
of the tumor. The most frequent degenerative change observed i: 
myxomatous degeneration of the stroma. The connective-tissue fibre: 
are separated by the myxomatous material, and the stroma present: 
the appearance of juvenile connective tissue. The tumor or part of ; 
tumor undergoing this process becomes softer. Calcification of th< 
stroma arrests the growth of the tumor affected by this change, th< 
parenchyma-cells degenerate, and the tumor becomes eventually com 
pletely petrified. Burow found cholesterin in a large lipoma of th< 
axilla. The lime-salts found in a calcified lipoma are carbonate anc 
phosphate of lime. Fiirstenberg found in the fat-cells lime-salts ir 
combination with fatty acids. Ossification of parts of the stroma occur: 
in rare cases. Oil-cysts have been found in the interior of fatty tumors 
and are supposed to have been formed by atrophy of the cell-envelope: 
and accumulation of their contents in the stroma. 

Anatomical Varieties. — All lipomata are encapsulated. The cap 
sule is perfect in the circumscribed variety ; in the diffuse form th< 
tumor sends out into the surrounding loose connective tissue pro 
longations which sometimes are not discovered in the removal of th< 
tumor, and lead to a recurrence of the growth. The diffuse form fre 
quently occupies a large territory, as, for instance, the anterior surfaci 
of the neck. The lipoma arborescens or racemosum described bj 
J. Miiller is a branching fatty tumor (Fig. 280). It is found mos 
frequently in the knee-joint, where it starts beneath the synovial mem 



LIPOMA. 



399 



brane, and, pushing this before it, sends branching lobes into the joint. 
Lipoma arborescens is also found quite frequently as a diffuse tumor 
under the peritoneum and the pleura. 

Symptoms and Diagnosis. — Lipoma frequently occurs as a con- 
genital tumor. Sometimes it is found as a symmetrical affection — for 
instance, the simultaneous occurrence of a lipoma in each axillary 
space. The writer has observed such a case in a woman fifty years of 



111k 



J§*./£ 




Lipoma arborescens (after Liicke). 



age. Billroth, in a paper published shortly before his death, called 
attention to the occurrence of symmetrical lipoma. As a post-natal 
tumor it commences most frequently after puberty. Its growth is 
always slow. Sometimes it remains stationary for a certain length of 
time, when, without any apparent provocation, it resumes its growth. 
It attains occasionally an immense size. Rhodius recorded a case in 
which the tumor weighed sixty pounds. Tumors weighing more than 
ten pounds, however, are very rare. If the tumor is subcutaneous, the 
skin over it, from tension, atrophies, and ulceration from impaired nutri- 



400 PATHOLOGY AND TREATMENT OF TUMORS. 

tion may take place. In other instances ulceration is caused by ; 
trauma or in consequence of irritating applications. Infection of a fatt) 
tumor through a break in the surface is frequently followed by intensf 
phlegmonous inflammation of the stroma of the tumor, extensive gan- 
grene, and profuse suppuration. 

Examination of a tumor complicated by acute inflammation mighi 
lead the surgeon to suspect a malignant growth. Under such circum- 
stances a careful consideration of the clinical history will prevent i 
mistake in diagnosis. A soft lipoma imparts to the palpating fingei 
a sense of fluctuation. Pseudo-fluctuation of soft tumors has led tc 
many mistakes in diagnosis. Chelius compares the sensation felt or 
palpating a lipoma to that felt on compressing a bag filled with cotton 
If the tumor is hard, the resistance to pressure is of a firm, elastic 
kind. A subcutaneous lipoma is a lobulated, movable tumor. Its slow 
growth differentiates it from sarcoma. A lipoma, however, may attain 
considerable size before being discovered by the patient, and surgeons 
have often been misled by dating the origin of the growth to its acci- 
dental discovery by the patient. In doubtful cases the negative result 
of an exploratory puncture will prove of great value in differentiating 
between a lipoma and an infective or cystic swelling. The recognition 
of a cavernous or telangiectatic lipoma is often impossible. This com- 
bination tumor should be suspected if under pressure the tumor is 
diminished in size, but the effect of pressure is less marked than in 
cases of deep-seated angioma. 

Prognosis. — The prognosis in lipoma is favorable. Transition into 
sarcoma is less frequently observed than in any other kind of benign 
mesoblastic tumors. Myxomatous degeneration of the stroma often 
initiates the transition of a lipoma into a sarcoma. This transition occurs 
most frequently in intermuscular lipomata. The first case of this kind 
was described by Forster. Virchow examined three fatty tumors which 
had undergone this degeneration, and made the statement that their 
malignancy depended upon the extent of the degeneration. The fat- 
cells are not affected by this change. Waldeyer showed that myxo- 
lipoma can give rise to metastasis. In a mesenteric tumor of this kind 
he found metastatic deposits in the liver and lungs. The pressure- 
effects are also less marked, owing to the location of the tumor being 
usually in places where the surrounding tissues are yielding. Even the 
large subserous lipomata seldom give rise to any serious functional 
disturbances. Patients with fatty tumors seek surgical advice more 
frequently for cosmetic reasons or for inconveniences attending the 
presence of the tumor than for the relief of suffering or the functional 
disturbances. 



LIPOMA. 401 

Treatment. — The only proper surgical treatment of lipoma is 
removal by excision. Lipoma of the abdominal cavity is rarely or 
ever recognized before the abdomen is opened. The removal of a sub- 
cutaneous lipoma must be done under strictest aseptic precautions, because 
the bed of the tumor presents the most favorable conditions for progres- 
sive infection. The numerous large connective-tissue spaces which are 
exposed by the removal of the tumor and the abundance of connective 
tissue forming its bed are admirably adapted for a diffuse infection. 
Before antiseptic surgery came in use numerous instances of progres- 
sive phlegmonous inflammation, sepsis, and pyemia occurred after the 
removal of small lipomata. The surgeon must not be lulled into a 
sense of ease and security offered by an easily-removable lipoma in 
undertaking its removal by enucleation. He must make as careful 
preparations to procure asepsis as though he were to operate tipon the 
abdominal cavity. Owing to the attenuated skin overlying tumors 
immediately under the surface, the incision, as a rule, should be made, 
not over the centre of the tumor, but at its base. A semilunar incision 
in this location will secure more room than a straight one. After reflec- 
tion of the flap the capsule of the tumor must be found, and in the 
enucleation which follows it is taken as a guide. Bands of connective 
tissue which convey the blood-vessels to the tumor should not be torn, 
but should be cut with scissors or with a knife. Tearing must be 
avoided. After the enucleation all bleeding points are tied. As few 
blood-vessels are cut in the operation, the wound can be sutured 
throughout. Drainage is unnecessary. The dressing must be applied 
with care in order to bring and to hold the wound-surfaces in uninter- 
rupted apposition. If the wound is sealed with cotton and iodoform 
collodion, an elastic dressing is applied over it to aid the sutures in 
securing and maintaining accurate coaptation of the wound-surfaces. 
In the majority of cases general anesthesia is superfluous in the removal 
of a lipoma. 

Topography. 

Subcutaneous Adipose Tissue. — By far the greatest number of 
fatty tumors originate in the panniculus adiposus and present them- 
selves as lobulated movable subcutaneous tumors. In this locality the 
tumor is occasionally multiple, from two to ten or more appearing 
simultaneously or in succession. Lipoma is found most frequently 
upon the neck (Fig. 281), shoulders, chest, abdomen, arms, and thighs. 
Grosch collected 716 cases of solitary lipoma, and found their regional 
distribution, in the order of frequency, as follows : Neck, back, thigh, 
forearm, volar side of hand and foot; the scalp only in exceptional cases. 
It appears, then, that lipoma occurs most frequently in localities where 



402 



PATHOLOGY AND TREATMENT OF TUMORS. 



the skin is scantily supplied with glands. Symmetrical lipomata Groscri 
regards as of neuropathic origin. Lipoma of the scalp is very rare. Ir 
this locality the tumor is flattened and never becomes pendulous 
Lipomata in localities where the skin is loose often become peduncu- 
lated. 

A neuropathic cause of symmetrical lipomata has been assumec 
by some. Madelung observed the growth of fatty tumors at the 
insertion of the deltoid muscle following neuralgia and tremors which 
occurred in consequence of contusions. In one of the two cases which 




Fig 



Diffuse lipoma of the neck (after Baker). 



he reported the neuralgia disappeared after extirpation of the tumor 
Mathieu in 1890 described a case in which sciatic neuralgia attendee 
two pairs of lipomata, one on the trochanter major, of the size of th( 
head of a new-born child, and two smaller ones, of the size of a fist 
on the inner side of the knee. Other tropho-neurotic affections com 
plicated the case. Targlowa recorded a case where symmetrica 
lipomata, seven pairs, had developed in a man affected with genera 
paralysis. The tumors occupied the neck, the zygomatic and mastoic 
processes, the subclavicular, the deltoid, and the sacral region of botl 
sides. Cases of the same nature are reported by Oldham, MacCormac 
Hutchinson, C. Beck, and others. In Beck's case the tumors occupiec 
the neck, the parotid, and the mastoid regions on both sides. Thi 



LIPOMA. 



403 



writer has seen only one case of diffuse lipoma of the neck, and in this 
instance the swelling extended diffusely around the whole neck and 
came up well in front of both ears. Diffuse lipoma is not encapsulated. 
The fat bears a coarsely granular appearance, due to being bound up 
in small lobules, which causes it to resemble omentum in its structure. 

Operative treatment in diffuse lipoma is not indicated, as a rule, as 
the tumor usually becomes stationary. 

The palm of the hand is occasionally the seat of a lipoma (Fig. 
282). The tumor in this locality might be mistaken for tuberculosis 
of the tendon-sheaths or for a 
plexiform neuroma. The very 
slow growth and the absence of 
pain are important factors in dif- 
ferentiating lipoma from neuroma 
and inflammatory swellings. 

Eyelids. — The " fibroma li- 
pomatodes " of Virchow, the 
"xanthoma," which is usually 
found upon the eyelids, appears 
as yellowish or brown spots and 
consists of large fat-cells with a 
reticulated protoplasm. The tu- 
mor is sometimes quite diffuse 
and large. Some authors have 
described xanthoma as a variety 
of endothelioma, but the cells 
of endotheliomata contain no 
fat except as a product of degen- 
eration. The coloring material 
is lipoxanthin, belonging to the 
class of blood-pigments. Klebs 
proposes for these tumors the name lipoxanthoma. Xanthoma may 
occur as a primary lesion in other parts of the body, more especially 
where the skin is exposed to repeated injuries. 

Subserous Lipoma. — The peritoneum, like the skin, rests upon 
a bed of fat, the thickness of which varies considerably. This 
layer of fat is sometimes the seat of very large fatty tumors. In 
Carlsberg's case the tumor weighed thirty-five pounds and was in part 
petrified. Terillon removed a subperitoneal lipoma weighing fifty-seven 
pounds. Homans of Boston removed two large retroperitoneal fatty 
tumors. The removal of large lipomata by laparotomy is a very dan- 
gerous operation : of 10 cases, only 3 recovered. Smaller lipomata 




Fig. 282. — Lipoma in the palm of the hand {after 
Sutton). 



404 



PATHOLOGY AND TREATMENT OF TUMORS. 



are frequently found in connection with femoral and inguinal hernias 
Roser believed that lipoma in subperitoneal spaces usually occupiec 
by herniae is a frequent cause of hernia. A subperitoneal tumor oi 
the anterior abdominal wall sometimes, by displacing the abdomina 
muscles, becomes subcutaneous, especially near the umbilicus. If the 
tumor is situated between the folds of the broad ligament, it simulate; 
very closely an ovarian tumor. The removal of omental lipoma ha; 
proved more successful than the removal of tumors from behind the 

peritoneum of the posterior ab- 
dominal wall. Meredith removec 
successfully an omental lipoma 
weighing fifteen and a half pounds 
Forster saw one that weighed fifty- 
three pounds. Waldeyer described 
a lipo-myxoma of the mesentery 
that weighed sixty-three pounds. 
Subserous lipoma of the colon 
is met with occasionally. The 
appendices epiploicae are often the 
seat of polypoid lipomata. Lipoma 
of the abdominal organs and of the 
subperitoneal layer of fat are not 
recognized before the abdomen is 
opened. If abdominal section re- 
veals the existence of a lipoma in 
the retroperitoneal space, its removal 
should not be attempted if, as is so 
often the case, it dips down deeply 
on the side of the vertebral column, 
unless the tumor interferes with an 
important function or is the cause 
of pain. If the tumor is more 
favorably located, the peritoneum 
covering it should be incised over the most prominent part of the 
tumor, and the tumor should be removed by enucleation. After the 
tumor is removed the peritoneal incision should be sutured. 

Submucous Lipoma. — Submucous lipoma of the gastro-intestinal 
canal is rare. Virchow examined a submucous lipoma of the stomach 
as large as a walnut. Turner has seen a fatty tumor, the size of a large 
walnut, growing in the submucous tissue of the large intestine and pro- 
jecting into the lumen of the bowel near the ileo-cecal valve. Sub- 
mucous intestinal lipomata may cause intussusception, and thus become 




Fig. 283. — Meningeal lipoma simulating a spina 
bifida in a child eight months old (after Temoin). 



LIPOMA. 



405 



a source of danger to life. A few instances of submucous lipoma of 
the larynx have also been reported. 

Meninges of the Brain and Spinal Cord. — Lipoma of the menin- 
ges of the brain and spinal cord is a heterotopic tumor which develops 
from a displaced matrix of lipoblasts. Tauber records a case where 
the tumor was located in the tubercula quadrigemina on the right side, 
and had given rise to destruction of brain-tissue from pressure. Roki- 
tansky has seen cases of lipoma upon the internal surface of the dura 
mater and in the lateral ventricle. Polypoid masses of fat are occa- 
sionally associated with protrusions of the spinal or cerebral meninges, 




Fig. 284.— Meningeal lipoma overlying the sac of a spina bifida (after Sutton). 

and fatty tumors may be found as a pathological curiosity in the central 
nervous system. Chiari found two lipomata the size of a pea under the 
arachnoid, and Weichselbaum found one in the posterior lobe of the 
hypophysis in a soldier twenty-two years old. Lipomata are frequently 
observed at the seat of a spina bifida occulta, which may even penetrate 
inside the theca (Fig. 2S3). 

In the cases of meningeal tumors examined by Recklinghausen 
and Obre the tumors contained striped muscular fibres, showing 
that the matrices were composed of displaced fetal tissue. A lipoma 



406 



PATHOLOGY AND TREATMENT OF TUMORS. 



complicating a spina bifida greatly complicates the diagnosis (Fig. 284) 
The presence of a solid tumor over the spine in children should induce 
the surgeon to look for, and to be prepared to treat, a spina bifida a 
its base. 

Intermuscular Lipoma. — Fatty tumors in rare instances have beer 
found between nearly all the great muscles, and have given rise t( 
great difficulty in diagnosis. Myxo-lipoma, according to Liicke 
occurs most frequently below the gluteal fold, between the muscle; 
of the thigh, and frequently penetrates the ischiatic foramen. 

Intermuscular lipoma being more liable than superficial tumors tc 
undergo transition into sarcoma, their operative removal is rendered sc 
much more imperative. 

Periosteum. — As a heterotopic tumor lipoma of the periosteun 
must be mentioned. Sutton collected nine such cases representing sc 




Fig. 285. — Lipoma arborescens of the shoulder-joint (after Sutton). 



many different bones. The heterotopic nature of periosteal lipomas 
has been established by microscopical examination, which in eacl 
specimen showed traces of striated muscle-fibre. Without an explora- 
tory incision or an examination of tissue removed it would be next tc 
impossible to make a positive diagnosis. 



LIPOMA. 407 

Joints. — Subserous lipoma of joints, from the location of the tumor, 
appears as a diffuse growth. The lobes of the branching tumor present 
a racemose or arborescent appearance ; hence these tumors are known 
and described as lipoma arborcscens. Subsynovial lipoma is found 
most frequently in the knee-joint, but has also been seen in the shoulder- 
joint (Fig. 285). The fringes of the tumor are covered by the synovial 
membrane. If the tumor disturbs the function of the knee-joint, its 
removal by arthrectomy is indicated. Thorough removal under strict 
antiseptic precautions is not followed by recurrence and yields a satis- 
factory functional result. 

Tendon-sheaths. — Lipoma outside the tendon-sheaths has been 
described by Ranke and Trelat. It is found most frequently along 
the tendon-sheaths of the flexor tendons of the hand. Lipoma inside 
the tendon-sheaths springs from the adipose tissue of the mesotendon. 
It develops usually as a multiple tumor which presents an arborescent 
appearance, and it is easily mistaken for tuberculosis of the tendon- 
sheaths and for plexiform neuroma. According to Hammann, Sprengel, 
and Haeckel, it can be treated successfully by excision. 

Bye. — Subconjunctival lipoma is a rare affection of the eye. It 
occurs most frequently near the point where the conjunctiva is reflected 
from the lower lid to the eyeball, and it is almost confined to children. 
As a rare retrobulbar benign tumor a lipoma is found in the cushion 
of fat behind the eyeball, producing, according to its size, more or less 
displacement of the eyeball. 

Broad Ligament. — Lipoma of the broad ligament as a subserous 
tumor is very rare. Pozzi saw a case of this kind in which the tumor 
was mistaken for an ovarian tumor because of the misleading sense of 
fluctuation. The patient suddenly died of embolism three days after 
an exploratory incision. 

Vulva. — Lipoma of the vulva arises in the fatty tissue of the mons 
veneris, and often reaches large dimensions. Stiegele operated on one 
which weighed ten pounds. In one of Bruntzel's cases the tumor 
increased greatly in size during pregnancy. 

Scrotum. — Lipoma of the scrotum occurs rarely as a subcutaneous 
tumor. Fatty tumors of the cord often reach considerable size. Park 
successfully removed a large lipoma of the cord, and he refers to a 
number of similar cases. 



XIX. MYXOMA. 



The frequent occurrence of myxomatous degeneration of the stroma 
of benign and malignant tumors and the rarity with which pure myx- 
omatous tumors are found have induced some authors to abandon 
myxoma as a separate class of tumors and to include it among the 
fibromata. Myxoma is a tumor which presents so many characteristic 
peculiarities that it is well to give it a separate place in the classification 
of tumors, and not to regard it as a variety of cedematous degeneration 
of other connective-tissue type of tumors. 

Definition. A myxoma is a tumor composed of mucous tissue resem- 
bling Wharton's jelly in the umbilical cord. Virchow selected Wharton's 

jelly of the umbilical cord as a prototype 
of the tissue of which a myxoma is com- 
posed (Fig. 286)- 

In the embryo the connective tissue is 
identical in structure with Wharton's jelly. 
The meshes of the cellular network are 
occupied by a semi-gelatinous, indifferent, 
and but slightly differentiated intercellular 
substance containing few fibres and occa- 
sional wandering cells. During the devel- 
opment of myxomatous into connective 
tissue the fibrous tissue in the meshes 
becomes more abundant, while the intercellular substance is diminished 
in quantity. If a group of cells should become arrested in their devel- 
opment at an early stage and be set aside, it is to be expected that 
tissue-proliferation from them would result in a connective-tissue tumor 
of lowly-organized tissue — a myxoma. On the contrary, arrest of 
development at a later stage would result in a tumor-matrix which would 
produce a connective-tissue tumor of a higher type — a fibroma. The 
stage at which development of the mucous cells in the embryo is arrested 
determines whether the tumor from such a matrix is to be a myxoma or 
a fibroma. The intrinsic capacity of mature connective tissue to revert to 
its original embryonic state accounts for the frequency with which the 
stroma of all tumors undergoes myxomatous degeneration. A post-natal 

408 




Fig. 286. — Connective-tissue cells from 
young umbilical cord: processes of cells 
unite to form protoplasmic network ; 
fibrous elements slightly developed (after 
Piersol). 



MYXOMA. 



409 



matrix of myxoma is created if the pre-existing connective-tissue cells 
revert to their original embryonic state and remain unspecialized. 

Histology. — The histological structure of a myxoma is subject to 
many variations. The variable structure depends on the amount and 
character of the intercellular gelatinous substance and the abundance 
and vascularity of its stroma. Mucin is a substance which in the living 
body is rapidly destroyed and eliminated. In a myxoma the retention 
of this substance gives rise to hydropic conditions, and this reten- 
tion occurs in myxomatous tumors if the production and absorption of 
mucin are arrested. 

Myxoma may occur as a clear, colorless, gelatinous mass which 
differs from fluid only in its greater consistence. The delicate stroma 
of such a jelly-like mass contains small blood-vessels which nourish 
the lowly-organized tumor-tissue. Such tumors are found in the 
antrum of Highmore. In the firmer variety the translucency is lessened 
by a more copious stroma and by larger blood-vessels. The prognosis 
in the latter form is less favorable than in the former, on account of 
the more active cell-proliferation. The capsule of a myxoma is com- 
posed of connective tissue which has become condensed by pressure 
on the part of the tumor-tissue. 

The typical myxoma is composed of a network of branching cells, 
the intercellular substance in its meshes being composed of a gelatinous 
homogeneous substance which contains mucin. The nuclei of the cells 
are large. If the cells of the tumor are few and the stroma is in an 
extremely hydropic condition, the 
tumor is called a hyaline myxoma 
(Fig. 2S7,a). If the cells are more 
abundant and less stellate, it is 
called a medullary myxoma (Fig. 
287, b). If the tumor is very 
vascular, we speak of a myxo- 
angioma. Klebs found that 
myxomatous degeneration takes 
place in cells which are in close 
proximity to blood-vessels, and 
that it appears first as a vacuole 
in the protoplasm of the cell. 
As a component part of other 
tumors, benign as well as malignant, myxomatous tissue is very com- 
mon, in which case the nomenclature of the tumor is modified by 
substituting a compound word for the single word and retaining the 
name of the primary tumor, as adeno-myxoma, chondro-myxoma, 




Fig. 287. — Myxoma : transition of (a) hyaline form into 
(b) medullary form; X 2 5° (after Perls). 



410 PATHOLOGY AND TREATMENT OF TUMORS. 

myxo-carcinoma, myxo-sarcoma, etc. The most frequent combinatior 
is myxoma with lipoma, lipoma myxomatodcs. 

Etiology. — Congenital myxomata have been reported by C. 
Weber, Schuh, and others. No age is exempt, but they are met wit! 
most frequently in young adults. The most potent exciting cause: 
are chronic irritation and inflammation. The formation of nasa 
myxomata is frequently preceded by chronic catarrhal inflammation 
Myxomatous polypi of the external auditory meatus are most alway: 
associated with chronic inflammation of the external ear. 

Symptoms and Diagnosis. — A myxoma is a soft, gelatinous, trans 
lucent, interstitial, sessile or pedunculated growth. It is of slow growth 
and as a surface tumor it does not attain large size. Its growth is 
unlimited if it receives its blood-supply from the entire periphery, as i: 
the case in interstitial myxoma. The diagnosis is not attended by anj 
difficulties if the tumor is accessible to sight and touch. Its color anc 
consistence distinguish it from fibroma, adenoma, and the malignanl 
tumors. Fluctuation is a constant sign, owing to the softness of the 
tumor-tissue. The transition of a myxoma into a sarcoma should be 
suspected when the tumor without any obvious cause begins to grow 
rapidly. In such cases an examination of the tumor-tissue under the 
microscope should be made before an operation is undertaken, as z 
correct diagnosis is of paramount importance in planning and executing 
an operation of sufficient thoroughness to remove all the infected tissues 
in case the tumor has become malignant. If the microscope is to bi 
relied upon in ascertaining whether or not malignant transition has taken 
place, tissue from the new part of the tumor must be obtained for exam- 
ination. Serious blunders in practice have arisen from the examination 
of old portions of the tumor, in which portions no traces of malignanl 
transition could be seen. Wherever possible, tissue from the base of 
the tumor should be taken for microscopic examination, as it is here 
that malignant transition is most frequently initiated. 

Prognosis. — A pure myxoma is a benign, local, encapsulated tumor 
Myxoma has received an unenviable reputation from a prognostic 
standpoint from the fact that it has been so often confounded with 
malignant tumors that had undergone myxomatous degeneration, anc 
from the frequency with which it undergoes transformation into sar- 
coma. A pure myxoma does not give rise to local, regional, or genera! 
infection. The implication of adjacent tissues, regional infection, anc 
general dissemination are positive proofs either that the primary tumoi 
was malignant and had undergone myxomatous degeneration or thai 
the tumor is no longer a myxoma, but is a sarcoma produced in con- 
sequence of transformation of a benign into a malignant tumor. Ir 



MYXOMA. 411 

rendering a prognosis in cases of myxoma the aptitude of such a tumor 
to undergo malignant transition must be remembered. The greater 
liability of myxoma than of fibroma to become transformed into a 
sarcoma is due to the more lowly organized cells of which its matrix 
is composed. 

Treatment. — Remembering the liability of myxoma to transition 
from a benign tumor into a sarcoma, it is necessary to emphasize the 
importance of early and thorough removal. Imperfect removal by 
operation or incomplete destruction by caustics has frequently been 
followed by a sarcomatous recurrence. The irritation incident to such 
imperfect treatment has proved sufficient to bring about a transition of 
the remnant of the tumor into sarcoma. The writer has more than once 
seen such a transformation follow incomplete removal of nasal polypi 
with the snare. It is especially necessary to remove the base of the 
tumor ; complete removal is seldom accomplished with the snare or by 
torsion. A hyaline myxoma of a mucous surface is so friable that its 
complete removal cannot be effected by avulsion. If the tumor is so 
located that its base cannot be reached for its removal by the snare or 
by avulsion, these procedures should be followed by cauterization with 
the Pacquelin cautery, in order to destroy every remaining vestige of 
the tumor. The removal of an intermuscular myxoma must be done 
with the utmost care, as the tumor usually has prolongations into the 
loose connective tissue surrounding it; these prolongations might be 
overlooked, and if not removed would become the source of a certain 
and early recurrence. 

Topography. 

Skin. — Myxoma of the skin occurs as a sessile or pedunculated 
tumor, but is rare as compared with fibroma or with papilloma. Myx- 
omatous tumors of the skin are most frequent in the neighborhood 
of the perineum and the labia in women. In young persons these 
tumors possess a regular, usually oval, outline. Later in life they 
shrink, and the surface of the tumor assumes a lobulated appearance 
(Fig. 288). These tumors ordinarily occur in the labium majus, although 
they may be found in the nymphse or in the perineum. 

Sessile myxomata are very prone to recur after removal, unless espe- 
cial care is taken to carry the incisions beyond the limits of the capsule. 
Enucleation is often attended by rupture of the capsule ; consequently 
this method of operating cannot be relied upon for complete removal 
of the tumor unless its capsule is unusually firm. 

Intermuscular Spaces. — Myxoma, like lipoma, is sometimes found 
to occupy the intermuscular spaces, and in this locality frequently 



412 



PATHOLOGY AND TREATMENT OF TUMORS. 



exists in combination with lipoma. The favorite locality, as has beei 
pointed out by Liicke, is the space between the external and interna 
hamstring muscles, below the gluteal fold. These tumors are of slov 

growth and may reach great size 
The writer has seen a myxoma th 
size of an adult's head between th 
adductor muscles of the thigh. L 
the excision of deep-seated myxom; 
it is often necessary to remove somi 
of the connective tissue around i 
in order to remove all the myx 
omatous tissue. 

Nose. — Unmixed myxoma oc 
curs more frequently in the sub 
mucous tissue of the nasal cavitie: 
than in any other locality. It start: 
usually in the mucous membram 
overlying the turbinated bones, anc 
only in exceptional cases in thi 
frontal sinus or in the antrum oi 
Highmore. The tumor is usually 
multiple, often from three to si? 
being found in one nasal cavity 
Frequently both nasal cavities an 
simultaneously affected. Thi 
growths may project anteriorly or in the direction of the pharynx 
During moist weather the tumors absorb moisture, swell, and produo 
more obstruction than during dry weather. If numerous and large 
they distend the nose, and when located in the frontal sinus bulging 
at the inner angle of the orbit takes place, like that produced b] 
hydrops or by empyema of this cavity. 

A nasal myxoma appears as a jelly-like, translucent mass whicl 
moulds itself to the cavity of the nose. It is covered by mucou 
membrane paved with columnar or stratified epithelium. Under thi 
microscope the tumor-tissue appears like very cedematous connective 
tissue. The great mass of the tumor is composed of myxomatou 
tissue in the meshes of the reticulum of connective tissue and paren 
chyma-cells (Fig. 289). The blood-vessels traversing the connective 
tissue stroma are usually quite large with very thin vessel-walls. Nasa 
myxoma occurs most frequently in persons from the age of puberty ti 
that of fifty years. 

The removal of nasal myxomata is by no means an easy operatior 




Fig. 288. — Pedunculated myxoma from the 
labium of a woman fifty years old : it had existed 
many years (aftei- Sutton). 



MYXOMA. 



4*3 



Avulsion with the different kinds of forceps devised for this purpose is 
usually followed by recurrence owing to incomplete removal of the 
tumor ; the use of the snare gives better results, but recurrence is by 
no means infrequent. In cases in which a permanent cure followed 
these procedures, usually a part of the turbinated bone to which the 




Fig. 289. — Myxoma of nose (Surgical Clinic, Rush Medical College, Chicago) : a, delicate connective-tissue 
stroma; S, granular amorphous myxomatous material, non-staining; c, nuclei ; d, blood-vessels. 

tumor was attached was removed with the tumor. Konig's operation 
should be resorted to if snaring and avulsion have not resulted satis- 
factorily. This operation consists in cutting through the ala of the 
nose on the side of the septum from within outward as far as the bony 
framework, thus rendering the base of the tumor more accessible. 
After locating the attachment of the tumor the index finger should be 
inserted into the nasal passage from the pharynx, and with it the tumor 
is pushed forward, when it may be removed with the snare or, what is 
perhaps better, the sharp spoon. If the tumor is attached far back, a 
temporary resection of the nose may become necessary to effect 
complete removal. This preliminary operation becomes absolutely 
necessary in the removal of polypoid tumors of the nose that have 
undergone malignant transformation. 

Middle Ear. — Myxomatous tumors in the external meatus are fre- 
quently preceded by chronic or acute inflammation of the middle ear 
and by perforation of the drum. These tumors usually spring from 
the mucous lining of the tympanum, filling this cavity and projecting 
into the external meatus through a perforation in the drum, causing 
deafness. Jacobson suggests that myxoma of the middle ear may in 
some instances arise from vestiges of connective tissue in this locality — 
an opinion which will be sustained by all who adhere to Cohnheim's 
theory regarding the origin of tumors. 



414 



PATHOLOGY AND TREATMENT OF TUMORS. 



The operative treatment of aural myxomata should be consigned tc 
skilled aural surgeons, as the reckless use of instruments and of caustic 
in the middle ear is calculated not only to destroy hearing, but ma) 
even be followed by fatal cerebral complications. 

Nerve-sheaths. — Myxomatous tumors are not infrequently founc 
in the central nervous system, the brain and the spinal cord. Myxoma 
of the sheaths of peripheral nerves is called neuroma 
myxomatosum. The tumors often occur multiple, anc 
they have been found in connection with diffused 
nerves (Fig. 290). They often produce serious func- 
tional disturbances in the form of neuralgia or paraly- 
sis. The most frequent seat of myxomatous tumors 
of the nerve-sheaths is the optic nerve. 

Glands. — In the mammary and salivary glands, 
the ovary, and the testicle myxomatous tumors occur 
frequently, but usually in combination with other 
benign tumors or as the result of regressive meta- 
morphosis of benign or malignant tumors. 




Fig. 290. — Myxoma 
of sheath of the ulnar 
nerve (after Hiiter). 



XX. CHONDROMA. 

Chondroma is a tumor which, according to its structure, is a close 
imitation of hyaline, reticulated, or fibrous cartilage. It occurs in parts 
of the body in which cartilage exists in the fetus, as in the epiphyseal 
extremities of the long bones, or it springs from an island of displaced 
cartilage-cells, as in the connective tissue, the parotid gland, the testicle, 
and the ovary. 

Definition. — A chondroma is a tumor composed of cartilage which is 
the product of tissue-proliferation from a matrix of chondroblasts. This 
definition refers all cartilaginous tumors to a matrix composed of 
embryonal cartilage-cells. 

Origin. — It has been customary to attribute to the connective tissue 
under certain conditions a chondrogenetic function. It is not more 
likely that connective tissue can produce cartilage than that it can pro- 
duce epithelial cells. In the study of the origin of tumors we must 
adhere closely to the teachings of Remak and Thiersch, that tissue 
begets tissue of its own kind. We have traced adenomata to localities 
where, in a normal condition, neither glands nor epithelial tissue exists, 
and we have to account for the presence of the tumor-matrix by the 
displacement of islets of adenoid tissue during the development of the 
embryo. We have to assign to heterotopic chondroma a similar origin 
by assuming as its starting-point the presence of a matrix composed 
of embryonic cartilage-cells or chondroblasts. Chondroma is some- 
times produced by a simple outgrowth from pre-existing cartilage, that, 
as a rule, attains no great size. Virchow names these growths ccchon- 
droses, and cites as their best examples outgrowths from the cartilages 
of the ribs, the cartilages of the amphiarthrodial joints, the cartilages 
of the trachea and the bronchial tubes, and from the cartilage between 
the basi-sphenoid and occipital bones in the young cranium. In such 
cases we must assume the existence of a superabundance of chondro- 
blasts which produce the localized hyperplasia, but which do not 
result in the formation of large tumors, owing to the inhibitory 
influence exerted upon the growth by the surrounding normal 
cartilage. 

415 



4i6 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 291. — Condyles and epiphyseal line 
of a rickety femur, with a cartilage island 
(after Sutton). 



In the majority of cases cartilaginous tumors are found connectec 
with the bones and the joints. Virchow in his classical article or 
" Chondroma " places great stress on the frequency with which sucr 

tumors spring from the epiphyseal car- 
fi A tilage. He found frequently in this 

Hk M locality, in adults, remnants of unossi- 

WiW^-' 1i™k ^ n:d c:irt, ' a t.' L " a centimeter and more ir 

^^^^^m^^^M^^. diameter. Such islands of cartilage- 

tissue are frequently seen in the epiphys- 
eal extremity of the long bones in rick- 
ety subjects (Fig. 291). 

It is well known that rickety persons 
are exceedingly prone to cartilaginous 
tumors. Virchow believes that a de- 
ficient blood-supply is often the cause 
of arrested ossification in such cases. 
The influences that excite proliferation in 
such embryonal remnants of cartilage are rickets and an hereditary pre- 
disposition. In glands and in other parts of the body in which nor- 
mally no cartilage is found the tumor springs from a displaced matrix 
of chondroblasts. Forster describes two cartilaginous tumors of the 
lung, as large as a bean, that had undergone partial ossification. In 
these cases the matrix was derived from the cartilage-rings of the 
bronchial tubes. 

Heterotopic chondroma occurs most frequently in the parotid gland 
and about the external ear, from tumor-cells which are derived from 
the cartilage of the external ear. In the vicinity of the external ear and 
the neck they occur as remnants of the first branchial cleft. Wartmann 
made a careful study of eight cases of chondroma in which the tumor 
developed independently of bone or cartilage. He is of the opinion that 
the tumor-elements start from ordinary fibrillary connective tissue, 
some of the fibres of which undergo hyaline degeneration ; the con- 
nective-tissue fibres proliferate actively, and form groups of cells which 
become surrounded by a capsule and are transformed into cartilage- 
cells. Other cells assume a stellate form ; the projections form free 
anastomoses with similar structures which constitute a network, the 
intercellular hyaline substance becoming softer, forming myxomatous 
spaces. Both forms of cells, prior to encapsulation, present glycogen 
reaction, which with the perfection of the capsule disappears. 

It is of course difficult to trace a tumor to its primary histogenetic 
origin, but it is no more difficult to explain the occurrence of chon- 
droma in connective tissue from a displaced matrix of chondroblasts 



CHONDROMA. 



417 



than to explain its presence in other tissues normally devoid of carti- 
lage-tissue, for which such an origin is generally conceded. 

Histolog-y. — The structure of a chondroma depends on the kind 
of cartilage it represents. 

Hyaline chondroma is composed of a uniform, dense, cartilaginous 
mass in which islands of cartilage can be seen surrounded by ground 
substance. The islands of cartilage-cells are not larger than a line or 
a line and a half in diameter (Fig. 292). The stroma of the tumor is 



.■■ ! -Ii >■■• ■ '■;.■■■■-'■."-■' •.•■"'■ - ■■':■ •'-'^v- r-.m: v ~w. W ' T-, ~ •*--; 

- . * v« ® v 

Lffi"-" '" T?\» »■-■£. /*< 









■■■:>::,' 


















* r~£.» 



•- * »3i 



,« 






vf W^' 



"~-i-'«& *~„r -'•»■ ®>/J *, -V^'S 






Fig. 292. — Hyaline chondroma of ilium ; X 130 (Surgical Clinic, Rush Medical College, Chicago) : a, amor- 
phous and granular stroma; b, cartilage-cells and capsule; c t cells in course of segmentation. 



supplied with blood-vessels, but the cartilage-masses are devoid of ves- 
sels of any kind. The spaces in which the cartilage-cells are enclosed 
are called " lacunae." The interior of these spaces is lined by a mem- 
branous structure from which the cells, after death, separate by shrink- 
age. The spaces are sometimes branched, and they have been described 
as " branched cells." 

Fibro-chondroma. — These tumors occur most frequently in the cap- 
sule of joints and in the fibrous structures adjacent to the parotid 
gland. In the latter location the tumor often reaches the size of a 
hen's egg. The tumor resembling fibro-cartilage is not so sharply cir- 
cumscribed as is the hyaline variety. The tumor-tissue consists of a 
uniform mass composed of fibrous tissue in the meshes of which car- 
tilage-cells are uniformly distributed throughout (Fig. 293). The cells 
frequently contain oil-globules. 

Reticulated Chondroma. — In this variety of chondroma the fibrous 

27 



418 



PATHOLOGY AND TREATMENT OF TUMORS. 



tissue is arranged in a reticulate manner and the spaces are occupiec 
by groups of cartilage-cells (Fig. 294). The vascular system of chon- 
droma is imperfect. Lymphatics and nerves have not been found. 



dJMi/iliA 1 ■, 1 ^ili^^Mlin!,/ 





Fig. 293. — Fibro-chondrotna from a cartilaginous Fig. 294. — Reticulated chondroma from index finger 
tumor of the parotid gland (after Lucke). (after Liicke). 

Retrogressive Metamorphoses. — Calcification is the most common 
regressive metamorphosis ; it begins at circumscribed points of the 




iiiilSiii 





Fig. 295. — Chondroma of index finger, show 



(after Lucke). 



and tabulated structure of the tumor 



tumor, and often terminates in the formation of large plates which are 
exceedingly hard and which have often been mistaken for bone. The 



CHONDROMA. 419 

granules of chalk form first in the capsules and later in the cells, and 
deposition in the intercellular substance takes place later. 

Cystic degeneration is often found in the interior of chondroma. 
Sometimes the tumor presents a honeycombed appearance from the 
presence of numerous small cysts. Coalescence of many cysts results 
in the formation of large irregular cavities. The softening which results 
in the formation of cysts is preceded by fatty degeneration of the carti- 
lage-cells. Fat-granules appear at different points in the protoplasm 
of the cells, and the fatty degeneration finally terminates in the dis- 
solution of the cells. At the same time the intercellular substance 
undergoes mucoid liquefaction. Hemorrhage into the cysts results 
in discoloration and pigmentation of the cyst-contents. If a cyst by 
ulceration on the surface is opened, there forms a fistulous tract which 
resists all treatment short of extirpation of the tumor. 

Development of cartilage-cells into bone is observed in chondromata 
of bone and periosteum as well as in those of soft parts. Complete 
ossification of the tumor has never been observed. The new bone 
appears in the form of spiculas representing cancellated bone (Fig. 295). 
The spiculas of bone form septa between the cartilage-masses. Very 
frequently small islets of bone are found disseminated throughout the 
tumor. 

Myxomatous degeneration is frequently observed in glandular 
chondroma. 

Cartilaginous tumors have always been looked upon with suspicion, 
as they are liable to undergo transformation into sarcoma. Wartmann 
asserts that embolism may occur in the centre as well as in the periphery 
of a chondroma, and that from the emboli secondary tumors develop 
with the assistance of the endothelial cells of the blood-vessels, the 
seat of the embolic process. It is more than probable that in all cases 
in which a chondroma invaded adjacent tissues, and in all instances in 
which metastasis occurred, the tumor had undergone transition into 
sarcoma. 

Etiology. — We have reason to assert that a chondroma cannot occur 
independently of the existence of a congenital matrix of chondroblasts 
or a post-natal matrix of embryonal cartilage-cells derived from the 
periosteum or the bone. O. Weber describes a case of multiple chon- 
droma of fifteen years' duration in a man twenty-five years of age. 
Regarding the heredity, it has been ascertained that the grandfather, 
the father, the brother, and one sister were also affected with the same 
disease. He alludes to similar cases proving the heredity of chon- 
droma. 

Chondroma of bone occurs usually before or at the age of puberty, 



420 PATHOLOGY AND TREATMENT OF TUMORS. 

while in other tissues it frequently appears later in life. Traurm 
appears to exert a powerful influence in stimulating a latent matrix of 
embryonal cartilage-cells to active tissue-proliferation. 0. Webei 
proved by statistics that in one-half of all cases of chondroma the 
origin of the tumor could be traced to a trauma. 

Rachitis is a frequent exciting cause of chondroma of bones. We 
can readily understand that the serious changes which occur in this 
disease in the bone surrounding a matrix of chondroblasts would excite 
tumor-growth by diminishing the physiological resistance of the adja- 
cent tissues. 

Symptoms and Diagnosis. — A chondroma, from the unequal 
growth of its different parts, always appears as a lobulated tumor, 
Lobulation increases with the size of the tumor. In central chondroma 
of the long bones the tumor is surrounded by a shell of bone that 
becomes thinner as the tumor increases in size ; this shell eventually 
disappears entirely by absorption. Periosteal and glandular chondro- 
mata are never surrounded by a complete shell of bone. Occasionally 
an attempt at the formation of such a shell can be seen, but it is always 
imperfect. 

A chondroma displaces, but does not infiltrate, the adjacent tissues. 
So long as it remains as a benign tumor it is surrounded by a capsule 
which completely separates it from the adjacent tissues. The tumor is 
hard except at points where cysts may have reached the surface of the 
tumor, which upon palpation would impart a sense of fluctuation. A 
chondroma may attain the size of an adult's head, but it may become 
stationary at any time, especially at the age of puberty. Ossification 
arrests tumor-growth in that part of the tumor which is the seat of 
such a transition. Tumor-growth is also arrested by calcification. 
Epiphyseal chondroma often appears in many of the long bones at the 
same time, and is commonest in rickety subjects. Chondroma always 
grows slowly. Its growth is not attended by pain or by tenderness. 
A tumor in the vicinity of a joint may by its presence interfere with 
full motion. The slow growth and the frequency with which it occurs 
as a multiple affection distinguish chondroma from osteo-sarcoma. 

The differential diagnosis between chondroma and osteoma can often 
only be made by resorting to akidopcirasty. If the tumor is an 
osteoma, the advance of the steel needle will be arrested when the 
surface of the tumor is reached ; if the tumor is a chondroma, the 
needle can be forced into the substance of the tumor. 

Prognosis. — Aside from the aptitude of a chondroma to undergo 
transformation into a sarcoma, the prognosis is favorable. Epiphyseal 
chondromata may impair the range of motion of adjacent joints, but 



CHONDROMA. 42 1 

otherwise functional disturbances do not occur. Glandular chondro- 
mata usually become stationary after they have reached a certain, and 
usually a very moderate, size. A chondroma upon the inner surface 
of the pelvis in females may complicate labor and necessitate Cesarean 
section. A chondroma of the shaft of the long bones may cause such 
a degree of atrophy of the bone by pressure that fracture will occur 
upon application of slight force. Chondromata of the bones usually 
become stationary after the completion of ossification of the skeleton. 

Treatment. — The removal of a chondroma is indicated only in 
exceptional cases. The removal of an epiphyseal chondroma should 
not be attempted unless the tumor interferes materially with the func- 
tion of an important joint or unless by pressure upon a nerve it causes 
pain. The removal of such a tumor should not be undertaken lightly, 
as during the operation recesses of the joint may be opened or bursa? 
overlying the chondroma may communicate with the joint. If the 
chondroma completely surrounds a long bone, its extirpation is out of 
the question, and amputation is only justifiable if the tumor is very 
large or its interior has become infected through a suppurating super- 
ficial cyst. Chondroma of the fingers, if pedunculated, can readily be 
extirpated. The same treatment will suffice in similar tumors of the 
shafts of the larger bones. Large encircling tumors of the phalanges 
may require amputation. 

In the removal of a chondroma of the long bones it must be 
remembered that the tumor usually has a central origin, and that 
removal on a level with the bone is generally followed by recurrence. 
The central part of the tumor must be removed with gouge and 
hammer to guard against a recurrence. The removal of chondromata 
of the soft tissues should be done by enucleation. If a chondroma 
manifests malignant properties, no time should be lost in making a 
correct diagnosis by the microscopical examination of sections of the 
tumor taken from the parts which are most suspicious ; in case the 
microscope reveals evidences of a malignant transition, the most 
radical measures must be resorted to, in removing not only the 
tumor, but also the adjacent infected tissues. 

Topography. 

Chondroma occurs most frequently in connection with bone and in 
organs situated in a locality where displacement of chondroblasts is 
most likely to occur. A post-natal matrix can occur only in bone- 
producing tissues, in bone, and in periosteum. 

Cartilage. — The overgrowth of cartilage Virchow calls " ecchondro- 
sis." Localized ecchondroses occur in four favorite localities — namely, 



422 PATHOLOGY AND TREATMENT OF TUMORS. 

along the edges of articular cartilages, of the laryngeal cartilages, o 
the cartilages of the ribs, and of the triangular cartilage of the nose 
The tumors never attain large size, and they resemble in many respect 
the osteomata. Ecchondrosis of the articular cartilage is found mos 
frequently in persons past middle life, in connection with the conditio) 
known as " rheumatoid arthritis." Bruns collected 14 cases of laryngea 




Fie. 296.— Lad twenty years of age with multiple chondromata (after Steudel). 

chondromata; of these, 8 were connected with the cricoid, 4 with 
the thyroid, 1 with the arytenoid, and 1 with the epiglottis. Small 
chondromata of the triangular nasal cartilage are quite common. They 
are sessile, and they hardly ever exceed in size a pea. 

Bone and Periosteum.— The existence of islands of cartilage in 
the interior of the long bones near the epiphyseal cartilages has been 
demonstrated by Virchow and others. A chondroma of bone always 



CHONDROMA. 



423 



springs from such a matrix or from a matrix of post-natal origin pro- 
duced by the bone-forming cells of the marrow or the periosteum. 
Periosteal chondroma is rare, and springs from a matrix of displaced 
chondroblasts or from a post-natal matrix produced by the cambium. 
The greater frequency of chondromata in rickety subjects is due, as 
Virchow pointed out, to the existence of islands of cartilage that have 
failed to undergo ossification, and which serve the purpose of a tumor- 
matrix. 

Epiphyseal chondromata often appear simultaneously in different 
parts of the skeleton, notably in the epiphyseal extremities of the long 
bones. The phalanges of the fingers and toes are favorite localities 
(Fig. 296). The tumors are always lobulated, and in the central variety, 
when the tumor is covered by a thin 
shell of bone, a crackling sensation 
is produced on pressure. In the super- 
ficial form enucleation can be effected 
without difficulty, while in the central 
variety it may become necessary to 
remove the remnants of the tumor 
with chisel and hammer. Unless the 
tumor interferes seriously with the 
function of a joint or causes pain by 
pressure upon a nerve (Fig. 297), ope- 
rative treatment is not indicated, as 
in the majority of cases limitation of 
the growth takes place at the age of 
puberty. If the tumor causes great 
inconvenience from its weight or 
becomes the seat of ulceration, ampu- 
tation may become necessary. A 
resort to a mutilating operation may 
become necessary if a fracture occurs 
at the place where the bone has become 
partially destroyed by the tumor. 

Joints. — Floating or loose cartilages are found most frequently in 
the knee- and elbow-joints. They are in the majority of cases sub- 
synovial chondromata which are formed at the margin of the articular 
cartilage, project into the joint, become pedunculated, and finally are 
detached, changing their position in the joint with the movements of 
the joint. A less frequent source of such loose fragments of cartilage 
in joints is the detachment of fragments of the articular cartilage by 
a trauma. The ecchondroses of the articular cartilage exhibit under the 




Fig. 297, — Chondroma of humerus, show- 
ing relations of tumor to vessels and nerves 
(after Liston). 



424 PATHOLOGY AND TREATMENT OF TUMORS. 

microscope a cartilaginous structure which has undergone partial cal- 
cification. They vary in size from a pea to double the size of the 
patella. In many instances the articular ecchondroses are multiple. 
Bentlif removed 1532 loose cartilages from the shoulder-joint of a girl. 
The presence of the foreign movable body usually produces hydrops 
of the joint. Impaction of the cartilage between the articular surfaces 
is attended by sudden pain and fixation of the joint — symptoms which 
continue until the cartilage becomes displaced to a part of the joint 
where its presence is less harmful. 

The most characteristic symptoms of a loose cartilage in a joint are 
attacks of sudden pain and arrest of function of the joint when the 
cartilage gets between the opposed surfaces of the joint, followed, as a 
rule, by more or less serous effusion into the joint. 

The removal of such cartilages from joints calls for special anti- 
septic precautions. Before the incision is made the cartilage should be 
immobilized in a sacculus of the joint by transfixing it with a stout 
aseptic needle. After the removal of the cartilage the capsule of the 
joint should be sutured separately with one or two catgut sutures 
before closing the external wound. The joint should be immobilized 
for at least a week or two. 

Salivary Glands. — Chondroma is found much more frequently in 
connection with the parotid than with the submaxillary gland. Of 12 
cases of chondroma in the soft tissues observed by Bryant, 9 occurred 
in the parotid, 2 in the submaxillary, and 1 in the leg. Chondroma is 
found in connection with the salivary glands more frequently than any 
other benign tumor. Liicke and Konig have shown that the tumor 
springs from the capsule of the glands or from the surrounding con- 
nective tissue, and as it enlarges it grows into the glands and becomes 
bound up with the gland-substance. The growth of such tumors is 
always very slow. They seldom exceed in size a walnut. They are 
movable and lobulated, and displace the surrounding tissues. 

The proper treatment is enucleation. This operation requires special 
care in the removal of benign tumors of the parotid gland, in order 
to prevent injury to the facial nerve and to Stensen's duct. The ex- 
ternal incision must be made with special reference to these structures, 
and the deep dissection must be made between two dissecting-forceps, 
dividing the tissues only after they have been identified. Incomplete 
removal of cartilaginous tumors is very often followed by transforma- 
tion of the remnant of the tumor into a sarcoma. A case of this kind 
has recently come under the writer's observation. A chondroma in 
the parotid gland in a woman thirty-five years of age had existed for 
twenty years. It was removed partially by a timid surgeon. Two 



CHONDROMA. 



425 



years later, when the case came under the care of the writer, there was 
found in the scar and involving the entire gland a sarcoma larger than 
a hen's egg. This case and many similar cases must impress the sur- 
geon with the importance of a careful and complete removal of all 
cartilaginous tumors when a radical operation is deemed advisable. 

Testicle. — In rare cases the testicle is the seat of pure and of mixed 
chondromata. Kocher recorded eight cases of pure chondroma. 
O. Weber saw a case of congenital chondroma of the testicle. The 
cartilage is usually hyaline, seldom fibrous. The great liability of chon- 
droma of the testicle to undergo malignant transformation is shown by 
the fact that in half the cases regional and general infection were 
noted. Paget reports a number of such cases in detail. The tumors 
are very hard and lobulated, with softer portions between the nodules. 
Unless the tumor is very small enucleation should give way to castra- 
tion. 

Ovary. — Chondroma of the ovary occurs very rarely as an isolated 
separate tumor. Kiwisch reported two cases of cartilaginous tumors 
of the ovary, but only in one case was the diagnosis corroborated under 
the microscope. Klob has shown 
that the cartilage in such tumors 
appears in the form of large fen- 
estrated plates in the periphery 
of the tumor, or forms granular 
prominences, or, finally, is dis- 
seminated through the fibrous 
stroma in groups of cartilage- 
cells the size of a pea. 

Connective Tissue. — In ex- 
ceptional cases chondromata 
occur in the subcutaneous and 
deep connective tissue in different 
parts of the body. Their origin 
in such unusual localities must 
be sought in displaced matrices 
of chondroblasts. The tumors 

are met with most frequently in situations where such displacements are 
most liable to occur — that is, in localities in close proximity to parts 
containing cartilage in the embryo. 

Chondroma Branchiogenes. — Chondromata in line with the first 
branchial tract spring from displaced islands of cartilage derived from 
the external ear. Some of the cartilaginous tumors in the vicinity of 
the hyoid bone may derive their matrix from the hyoid bone and larynx, 




Accessory auricles of neck (after C. Beck). 



426 



PATHOLOGY AND TREATMENT OF TUMORS. 



as suggested by Callender. A number of writers have described acces 
sory auricles in lines of the branchial tracts. Beck of Chicago recentlj 
described such a case. Some of these isolated islands of cartilage have 
become the matrix of cartilaginous tumors the size of a hen's egg anc 
larger. Heusing describes the case of a large cystic chondroma of 
the neck. In Schaffer's case the tumor was of the size of an egg 
beneath the skin on the side of the neck. Beck described a case of 
accessory auricles of the neck in a man forty-eight years old (Fig. 298) 







Fig. 299. — Cartilage from accessory auricles of neck (after C. Ecck) : a, perichondrium ; b, new cartilage-cell 
under perichondrium ; c, reticulum; d, islands of cartilage-cells surrounded by stroma of fibrous tissue. 

He removed a particle of one of the cartilaginous masses and subjectec 
sections of it to microscopical examination. The sections showed tht 
typical structure of cartilage (Fig. 299). 

In the majority of cases of branchiogenous chondroma the matri? 
remains latent until after the age of puberty, as in most of the fourteei 
cases so far reported the tumors did not develop until some time afte 
puberty. 



XXI. OSTEOMA. 

Definition. — An osteoma is a tumor which possesses a structure 
resembling that of cancellous or compact bone, produced from a con- 
genital or post-natal matrix of osteoblasts. Osteomata occur usually in 
connection with some part of the skeleton, but they are also found in 
parts and organs that have no genetic relations with the skeleton, as in 
the pia mater and the brain. It is doubtful if the tumors which are not 
in connection with bone present the structure of bone so perfectly as do 
osseous tumors of the skeleton. Fleischer described an osteoma of the 
tendon of the ilio-psoas muscle in which he found the Haversian canals 
and the medullary tissue arranged in the same typical manner as in 
normal bone. In another heterotopic osteoma described by the same 
author the tumor was situated upon the inner surface of the dura mater. 
In both instances bone-production was traced to the connective tissue 
and independently of the presence of osteoblasts. According to 
Fleischer's interpretation, the connective tissue at the seat of tumor- 
formation became more vascular and presented active tissue-prolifera- 
tion, and was transformed into hyaline masses in the interior of which 
the bone-cells appeared. The hyaline lumps become coalescent and 
undergo calcification. Osteoblasts were active in the further develop- 
ment of bone. The capacity of connective tissue to produce bone 
has been recognized for a long time, and this view of the bone-pro- 
ducing power of connective tissue is accepted by most of the modern 
pathologists. 

A distinction must be made between calcification and ossification of 
connective tissue. The production of bone is carried on in the embryo 
by a distinct and specific part of the mesoblast, resulting in the forma- 
tion of the skeleton and the growth of bone, and the production of 
new bone can take place only from a matrix of cells derived from the 
osseous system. The displacement of osteogenetic matrices into the sur- 
rounding tissues is as liable to occur as the displacement of matrices of 
cpiblastic and hypoblastic tissue. Heterotopic osteomata are usually 
found in close proximity to a bone. Heterotopic matrices of osteoblasts 
usually result in impeifect development of the tissue of the tumor. 
Virchow found in the apex of the lung an osteoma in which Haversian 



428 PATHOLOGY AND TREATMENT OF TUMORS. 

canals and medullary spaces were absent. Steudener found a numbe 
of small osteomata near the trachea, but entirely distinct from its rings 
Lesser found in the lung an osteoma which presented under the micro 
scope all the histological elements and the typical structure of bone. 

The metaplastic theory concerning the origin of bone is no longe 
tenable. A careful etiological distinction must also be made betweei 
a true osteoma and an exostosis. The origin of the former must b( 
restricted within the limits of the definition to a growth of bone fron 
a matrix of osteoblasts either in the bone or by displacement from ; 
bone, while the latter is the result of a localized or diffuse hypertroph) 
usually following a reparative process. 

Histogenesis. — The osteomata representing compact bone are usu- 
ally found upon the surface of bone, and they appear to be producec 
from the periosteal osteoblasts, as in the case of bony tumors of the 
flat bones of the skull and of the shafts of long bones ; or the) 
begin as chondromata, and proceed most commonly from the epiphys- 
eal lines and from the places of origin of ecchondroses. The lattei 
group of tumors, which have therefore a mode of origin distinct frorr 
the preceding, are usually pedunculated, are covered with cartilage 
and possess a cancellous structure continuous with that of the bone 
from which they arise. Osteomata from a displaced matrix of osteo- 
blasts are found most frequently at the insertion of tendons. Ossifica- 
tion of the deltoid from the shouldering of arms in the soldier, ossi- 
fication of the adductors of the thighs in cavalrymen, and the more 
diffuse bone-formation in myositis ossificans do not belong to osteoma 
but occur as one form of muscular degeneration. 

Histology. — In spongy osteoma (Figs. 300, 301) the cancellated 
structure of the bone is well shown in decalcified stained sections. If 
the tumor starts in the bone, it is surrounded by a zone of connective 
tissue which separates it from the surrounding tissues. In the ivory- 
like tumors upon the surface of the cranial bones and the shaft of the 
long bones the lamellae are so compact that the medullary spaces and 
the blood-vessels cannot be identified. The section of such a tumoi 
resembles ivory in compactness. In periosteal osteoma the tumor is 
at first not connected with the underlying bone, and at this stage can 
readily be detached. Later the surface of the tumor becomes attached 
to the bone and receives from it a part of its vascular supply. After 
the union has become complete a section through the tumor does not 
show the line where the union was effected. 

In the development of an osteoid chondroma into an osteoma the 
different phases of transition of cartilage into bone-tissue can be 
observed. Osteoma is almost immune to the different regressive meta- 



OSTEOMA. 



429 




Fig. 300. — Spongy osteoma of cranium ; X 250 (after Perls) : a, old bone-tissue with thick cancelli parallel 
with the surface ; b, young spongy bone-tissue with irregularly-arranged cancelli. 




Fig. 301. — Osteoma of finger ; X 30 (after Karg and Schmorlj. The tumor (a), separated by a narrow 
zone of connective tissue {&) from the epithelium of the surface (c), consists of cancellous tissue. The nar- 
row cancelli with delicate contour include the bone-cells, which appear as minute black dots and are covered 
on the surface with cells arranged like epithelium. Between the cancelli is a substance like myeloid tissue, 
which toward the periphery of the growth shows many nuclei. 



430 PATHOLOGY AND TREATMENT OF TUMORS. 

morphoses which have been described in connection with the othe: 
benign mesoblastic tumors. 

Transformation of an osteoma into a sarcoma has never, to th< 
writer's knowledge, been observed. 

Anatomical Varieties. — Osteoma durum or eburuaim resemble: 
ivory by its hardness ; it is found most frequently upon the outsid< 
of the skull. Osteoma spongiosum resembles the cancellated structun 
of bone, and usually takes its origin from the epiphyses of the long 
bones. As the tumor is usually covered with a thin crust of cartilage 
Virchow used the term exostosis cartilaginca. Enostosis is a tern 
applied to a bony tumor which originates in the interior of a bone 
Exostosis apophytica is a term introduced by Virchow to denote the 
origin of a bony tumor in a tendon independently of the bone to whicr 
it is attached. A tuberous osteoma is an osseous tumor with a con- 
tracted, pedunculated base, as is the case in osteomata of the frontal 
sinus, the antrum of Highmore, and the orbit. Callus luxurious is a 
term used to designate an osteoma produced at the seat of a fracture 
(Van Heekeven). 

Symptoms and Diagnosis. — An osteoma always grows very 
slowly, and becomes stationary after it has reached a certain limited 
size. It is not attended by pain or by tenderness. The slow growth 
and the absence of pain and tenderness distinguish it from inflamma- 
tory swellings of bone. Sarcoma of bone is usually a painless affection 
but it increases in size more rapidly than osteoma, and its growth is 
progressive. Osteoma is frequently a multiple affection like chondroma, 
while sarcoma as a primary disease of bone seldom if ever appears 
except as an isolated tumor. The differential diagnosis between an 
osteoma and a chondroma can often be made only by resorting tc 
akidopeirasty. 

Prognosis. — The prognosis in osteoma is always favorable. Trans- 
formation into sarcoma does not take place, and regressive metamor- 
phosis of any kind is almost unknown. In the female, pelvic osteomata 
may become a source of danger to life by interfering with the passage 
of the child through the pelvis. As the osteoma rarely attains great 
size, ulceration of the skin is seldom observed. Osteomata in mucous 
cavities occasionally necrose and give rise to a continuance of sup- 
puration until they are removed by operation. Osteoma of the orbit 
by displacing the eyeball may cause impairment of vision and expose 
the eye to destructive inflammation from exposure. 

Treatment. — The indications for surgical interference in the treat- 
ment of osteoma are the same as in chondroma. This statement 
should be modified in so far that operative removal is less urgently 



OSTEOMA. 



43 1 



demanded in osteoma than in chondroma, because in chondroma there 
is some liability of the tumor undergoing malignant transformation, 
which is not the case in osteoma. The removal of an osteoma of bone 
should be done either with a fine saw or with a sharp, thin chisel. 

Topography. 

Cranial Bones. — The cranial bones are the most frequent seat of 
osteoma durum, or ivory exostosis. The tumors, which are occasion- 
ally multiple, are found most frequently upon the frontal bone, 
especially at or near the superciliary arch. The tumors are smooth 
with a wide base, and the overlying skin is usually intact. In con- 
sequence of a trauma or of the application of irritating salves or 
lotions ulceration of the skin will occasionally ensue. 

Osteomata of the cranial bones must be distinguished from syphilitic 
exostosis by a careful inquiry into the history of the case and by the 
exclusion of all signs and symp- 
toms suggestive of an inflam- 
matory origin. The removal 
of such tumors, in the absence 
of complications such as shown 
in Figure 302, is usually done 
only for cosmetic considerations. 
If an operation is decided upon, 
it should be performed under 
strictest antiseptic precautions, 
with a view of obtaining primary 
healing of the wound and of 
preventing necrosis, and pos- 
sibly also pyemic complications, 
which might result from sup- 
purative infection. The tumor 
should be well exposed by a 
semilunar incision following its 

base. After reflecting all the FlG 302 . —Osteoma durum of the frontal bone with 

Soft tissues With the skin-flap, superficial ulceration (after Textor). Tumor removed by 

r Texlor. 

the tumor should with a very 

fine saw be sawed off even with the surrounding bone. For this pur- 
pose the writer prefers a scroll saw to the metacarpal or butcher's saw. 
By using the scroll saw the cut surface can be made to correspond 
with the outlines of the surface occupied by the tumor. After all 
hemorrhage has been arrested the soft parts are replaced carefully and 
are sutured with fine catgut or with horse-hair. The wound should be 




432 



PATHOLOGY AND TREATMENT OF TUMORS. 



sealed with cotton and iodoform collodion, over which an elastic com- 
press is to be applied for the purpose of keeping the flap in uninter- 
rupted contact with the sawn surface of the bone. In Guy's Hospital 
Reports for 1864 four cases of ivory exostosis of the skull are described. 




Fig. 303. — Osteoma of the left frontal sinus, anterior view (after Sutton). 

In all of them the tumors were removed with a fine saw, as they were 
too hard to chisel. 

The internal surface of the skull is occasionally the seat of an 
osteoma. The small conical exostoses which Virchow describes as occa- 
sionally growing from the upper surface of the basilar process into the 




Fig. 304. — Osteoma of the left frontal sinus, seen from below (after Sutton). 

cranial cavity are ossifications of outgrowths of cartilage connected wit! 
the basicranial synchondrosis, and a thin layer of cartilage often remain: 
on the surface of the tumor. Osteomata have been found upon th< 
inner surface of nearly all the cranial bones, but more especially upoi 
the frontal. Endocranial osseous tumors, when they reach consider 



OSTEOMA. 



433 



able size, disturb the function of the brain by causing irritation and 
pressure-atrophy, which are frequently manifested by well-defined focal 
symptoms. 

Frontal Sinus. — Osteomata of the frontal sinus belong to the 
tuberous variety. Their origin from islands of persistent cartilage has 
been described fully by J. Arnold. An interesting specimen represent- 
ing an osteoma in this locality (Figs. 303, 304) is preserved in the 
museum of the Royal College of Surgeons, London. Many of these 
tumors extend into the orbit, and others sometimes enter the cranial 
cavity through the orbital roof. The tumor in this locality sometimes 
attains a very large size, growing externally and in the direction of 
the cranial cavity. One of the largest specimens of this kind is in 




Fig. 305. — Osteoma of the frontal sinus (after Paget). 



the Museum of the University of Cambridge, England. Clark, who 
examined this tumor, found in the hardest parts neither Haversian 
canals nor lacunae ; in the less hard parts the canals were very large 
and the lacunae were not arranged in circles around them ; and every- 
where the lacunae were of irregular or distorted forms. In a case 
examined by Turner the bony growth from the inner table and orbital 
plate of the left frontal bone, which had a knotted, irregular, cerebral 
surface, caused a considerable indentation in the anterior part of the 
left frontal lobe of the cerebrum. In the absence of suppurative in- 
flammation of the frontal sinus the presence of the tumor is indicated 
by an expansion of the anterior wall of the sinus and by displacement 
of the eye if the tumor has extended in the direction of the orbit. 
Headache and focal symptoms would point to the extension of the 
tumor toward the cranial cavity. 

Suppurative inflammation often results in detachment of the pedicle 



434 



PATHOLOGY AND TREATMENT OF TUMORS. 



of the tumor, when the osteoma becomes a sequestrum in the suppu 
rating cavity. Cases of this kind have been described by Dolbeau 
Volkmann, Badal, Fenger, Socin, and Konig. 

An osteoma large enough to expand the frontal sinus should b< 
removed by operation. The operation is not a difficult one if the 
osteoma has necrosed. In such cases the anterior wall of the sinus i: 
resected with the chisel and the loose sequestrum is extracted, aftei 
which the cavity is carefully disinfected, drainage into the nasal cavity 
is established, and the wound is sutured with the exception of the 
lower angle, which is used as an additional point for drainage. If the 
osteoma remains attached, its removal is attended by more difficult) 
and requires a larger opening. In such cases it would be advisable tc 
make a temporary resection of the anterior wall of the frontal sinus 
in order to prevent the unsightly deformity which follows the loss of 
so much bone. The pedicle of the tumor should be traced carefully 
to its point of attachment to the bony wall of the sinus, when it is 
severed with a chisel. 

External Meatus.- — Osteomata of the external meatus, which are 
not uncommon, are of importance, as they are apt to obstruct the 
meatus and cause deafness. The tumors always spring from an islanc 
of cartilage-tissue ; these islands are present in great numbers during 
the development of the external ear. Seligmann has given a very 

accurate description of osteoma of 
the external meatus. If the tumoi 
encroaches sufficiently upon the 
meatus to threaten deafness, i1 
should be removed with a smal 
chisel and a hammer after detach- 
ing from it freely the surrounding 
soft tissues. 

Jaws. — Osteoma of the jaws is 
of very rare occurrence, and some 
of the tumors described as sue! 
have been cases of odontoma. The 
tumor may appear as an enostosi; 
or an exostosis, and usually belong; 
to the hard variety. Removal i: 
necessary only if the tumor inter- 
feres with speech or with mastica- 
tion or if it causes an unsightly deformity. In the case of symmetrica 
osteomata of the upper maxillae described by Hutchinson the tumor? 
had taken their starting-point from the nasal processes (Fig. 306) 




Fig. 306. — Symmetrical osteomata of nasal processes 
of maxillas (after Hutchinson). 



OSTEOMA. 



435 



Paget describes a specimen of an osseous tumor of the lower jaw. The 
tumor appeared as a nodulated mass nearly three inches in diameter, 
invested the right angle of the jaw, and was in its whole substance as 
hard and as heavy as ivory. He refers to another specimen in which 
ivory-like osseous tumors were formed in connection with the outer 
and inner surfaces, especially the latter, close to the alveolar border. 
Osseous tumors of the jaws are more frequent in the lower animals 
than in man. The antrum of Highmore and the nasal processes of the 
superior maxillae are sometimes the seat of large and disfiguring osseous 
tumors. 

Brain. — -Heterotopic osteomata are occasionally found in the brain. 
Some of these tumors are connected with the meninges ; others have 
their origin in the brain independently of its envelopes. These tumors 
spring from a displaced matrix of cartilage-tissue or of osteoblasts. 
Maschede describes an osteoma which was attached to the pia and 
which produced epilepsy and idiocy. Bidder found an irregular 
denticulated osteoma four centimeters in diameter in the left corpus 
striatum. The patient was the subject of 
contracture of the left arm and leg since 
infancy, the left leg being shortened two 
centimeters. In the case reported by 
Ebstein the tumor was located in the 
cerebellum and produced no symptoms. 
In operations upon the brain for epilepsy 
or other focal or cerebral symptoms 
osteoma as a possible cause should be 
remembered. 

Epiphyses of the Long Bones. — By 
far the greatest number of osteomata 
occur in the epiphyses of the long bones. 
Their origin is similar to that of chon- 
dromata in the same locality, only that in 
this instance the chondroblasts undergo a 
higher degree of development and the 
chondroma is transformed into an osteo- 
ma. Syme met with cases of epiphyseal 
osteoma in which the tumor was sur- 
rounded by a sort of synovial capsule ; in 
other cases the tumor projects into the joint. 

Epiphyseal osteomata are often multiple like the chondromata, and 
are nearly always covered by a thin crust of cartilage, resembling in 
this respect the articular extremities. The tumors, which are composed 




Fig. 307.— Exostosis of the femur 
(after Orl'AVi: its surface was clad with 
cartilage and surmounted by a bursa. 



436 PATHOLOGY AND TREATMENT OF TUMORS. 

of cancellous bone-tissue, are often supplied on their surface with i 
bursa interposed between the tumor and the fascia, tendons, or muscle: 
overlying it. Occasionally an osteoma is pedunculated, and frequently 
it has a broad base. The tumors are painless, but they often produce 
pain by pressing on adjacent nerves. 

A favorite locality for osteoma is above the inner condyle of the 
femur (Fig. 307), close to the insertion of the adductor magnus. In this 
locality the tumor is peculiarly apt to acquire a narrow, pedunculatec 
base. The pedicle of such a tumor may occasionally fracture, as hap- 
pened in the cases reported by Paget and Lawrence. Epiphyseal 
osteomata, unless of great size, seldom interfere with the functions of 
adjacent parts, and unless this is the case operative treatment is contra- 
indicated. 

Muscles and Tendons. — Osteomata are occasionally found in soft 
parts as distinct and discontinuous tumors invested with capsules of 
connective tissue. Paget refers to a tumor of soft cancellous tissue 
occupying the dorsal surface of the trapezial and scaphoid bones, com- 
pletely isolated from them and from all .the adjacent bones. In the 
museum of St. George's Hospital, London, is a tumor formed of com- 
pact bony tissue that lay over the palmar aspect of the first metacarpal 
bone, loosely imbedded in the connective tissue, and easily separated 
from the flexor tendons of the fingers. 

Exostoses tendineae have frequently been observed. The bony 
growth originated in the tendon, independently of the bone to which 
the tendon was attached. Folk removed an exostosis apophytica which 
was attached with a broad base to the sacrum and which terminated 
in a conical projection several inches in length in the gluteus maximus. 

Seat of Fracture. — Under certain circumstances the callus in the 
repair of a fracture is so profuse that a large bone-tumor remains aftei 
consolidation has been completed. Van Heerkeven applied to this 
condition the term callus litxurians. A good example of this condition 
is furnished by the bony hyperplasia which often occurs around a frac- 
tured rib in a lower animal. Such enormous permanent callus-forma- 
tion has been observed by Konig and others as one of the remote 
results of fracture. In some cases it has been impossible to make 
a differential diagnosis between an osteoma at the seat of fracture anc 
an osteo-sarcoma. The tumor under such circumstances springs fron 
a post-natal matrix of osteoblasts produced by the injury. The differ- 
ence between a superabundant callus and an osteoma at the seat of 
a fracture is that in the former case the provisional callus disappears 
or is at least greatly diminished in size, while an osteoma remains per 
manently as a bone-tumor. The operative removal of such an osteom; 



OSTEOMA. 437 

may become necessary if the tumor implicates important muscles, ves- 
sels, or nerves. An operation should not be undertaken until by the 
clinical course the true nature of the tumor has been revealed, by 
which means only is it possible to make a differential diagnosis between 
a superabundant provisional callus, an osteo-sarcoma, and an osteoma. 

Orbit. — Osteoma of the orbit occurs either as a primary tumor, 
when it is attached to the bony wall of the orbit, usually on the nasal 
side, or the tumor reaches the orbit from the frontal sinus or from the 
antrum of Highmore. In the latter case the appearance of the tumor in 
the orbit is usually preceded by signs and symptoms which point to its 
primary location in either of the adjoining cavities. In a case of orbital 
osteoma that recently came under the observation of the writer, con- 
siderable exophthalmos was observed and the eye was displaced out- 
ward. Beneath the orbital arch a hard tumor could be felt under the 
upper eyelid, at the inner angle. The tumor, which was exposed by 
an incision along the superciliary arch, was an inch and a half in length, 
and was attached to the inner wall of the orbit by a contracted, almost 
pedunculated, base. The tumor was detached from the bony wall with 
a narrow chisel, and was removed without inflicting any injury upon 
the more important contents of the orbit. The eye after the operation 
gradually resumed its normal position. If the tumor is located pri- 
marily in the frontal sinus or in the antrum of Highmore, its removal 
must be preceded by a temporary resection of the anterior wall of the 
cavity in which it is located. 

Bye. — Schiess-Gemuseus collected eight cases of osteoma of the 
eyeball. In each case the tumor occupied the elastic lamella and the 
choroid capillaries. 

Subungual Osteoma. — The last phalanx of the great toe is not 
infrequently the seat of a subungual osteoma (Fig. 
308). It always grows on the margin, and usu- 
ally on the inner margin, of this bone. The tumor 
projects under the edge of the nail, lifting it up, 
and thinning the skin that covers it until an ex- 
coriated surface is presented at the side of the nail. 
The growth of the tumor is usually very slow, 
and when it has reached a diameter of from one- FlG . 3o8 ._ Suburgualoste . 
third to one-half an inch it becomes stationary, oma of the great toe (after 
The extirpation of subungual osteoma with cut- 
ting forceps must be preceded by partial or complete removal of 
the nail. 




XXII. ODONTOMA. 



Definition. — An odontoma is a tumor composed of dental tissue i> 
varying proportions and in different degrees of development, arising fron 
teeth-germs or from teetli still in the process of growth. This definitior 
and the description of the different varieties are gleaned from Sutton': 
excellent work on Tumors, which contains the most accurate accoun 
of tumors of dental origin. 

Sutton's Classification of Dental Tumors. — 

i. Epithelial odontome, from the enamel-organ. 

2. Follicular odontome, 

3. Fibrous odontome, 
\. Cementome, 

;. Compound follicular odontome, 
5. Radicular odontome, from the papilla. 
7. Composite odontome, from the whole gum. 

1. Epithelial Odontomes. — These tumors (Figs. 309, 310) occur, as 
a rule, in the mandible, but they have been observed in the maxilla 



4- 

5- 
6. 

7- 



f from the tooth-follicle. 



f=~\ 



K3L 




Fig. 309. — Epithelial odontome ; natural size (after Sutton). 

(Sutton). They are encapsulated and contain numerous small cysts 
In color they resemble myeloid sarcoma, for which they have beer 
mistaken. They consist of branching and anastomosing columns of 
epithelium, portions of which form alveoli. Although they may occui 
at any age, they are most frequent at the age of puberty. 

2. Follicular Odontomes. — The follicular odontomes are the den- 
tigerous cysts (Fig. 31 1). They occur commonly in connection with 
teeth of the permanent set, and especially with the molars. The 

438 



ODONTOMA. 



439 



tumors often attain large size. The wall of the cyst may be very thin, 
so that it crepitates under pressure. The cavity contains a viscid fluid 
and the encysted tooth, which is often imperfectly developed. 




Fig. 310. — Microscopical characters of an epithelial odontome (after Sutton). 




Fig. 311. — Follicular odontome; 
natural size (after Sutton). The tooth 
has a truncated root. 



Dentigerous cysts rarely suppurate. Three cases of follicular odon- 
tome have come under the writer's observation. In one case the cyst 
was as large as an orange and contained an imperfectly developed 
molar tooth and a clear viscid fluid. In the 
second case a fistulous opening led into the 
bone above the permanent molars, and ne- 
crosis of the maxilla was suspected. The 
patient had been treated for a long time for If 
suppuration of the antrum. At the bottom 
of the cyst part of a molar tooth was found. 

A follicular odontome invariably occurs in 
connection with teeth the eruption of which is 
retarded or prevented from their being devel- 
oped in an abnormal position, whereby they become impacted by the 
surrounding bone. These tumors appear at a period of life succeeding 
that at which the alveolar portions of the maxillae are in a state of 
active development, in which they readily furnish an amount of bone 
sufficient to perfectly envelop the tooth. The capsule of the tooth, the 
remains of the enamel-organ, has been shown by Tomes to be, after 
the calcification of the enamel, quite free and detached from that struc- 
ture, and therefore, being attached only to its surroundings, will be 
carried away from the surface of the enamel with them ; there will 
thus be left a space into which, as a matter of course, serous fluid must 
under atmospheric pressure be effused, and thus there is formed a 
cyst, the walls of which will be the dental capsule, including the pro- 
jecting crown of the tooth (Coleman). 



44o 



PATHOLOGY AND TREATMENT OF TUMORS. 




312. — Fibrous odontome from 
natural size (after Sutton). 



goat; 



3. Fibrous Odontomes. — The fibrous capsule of a tooth composec 
of an outer firm wall and an inner loose layer of tissue may becom< 

thickened, constituting with the con 
tained tooth a fibrous odontome (Fig 
312). Such a tumor is often mistaker 
for a fibroma, especially if the tooth be 
small and ill-developed. Under the 
microscope fibrous odontomes presen 
a laminated appearance with strata oi 
calcareous matter. Rickets appears tc 
play an important part in the produc 
tion of fibrous odontomes. 

4. Cementomes. — A cementome i: 
a fibrous odontome which has under- 
gone ossification. The tooth in sucl 
cases is encapsuled in a mass of cementome. Cementomes occur mosi 
frequently in horses (see Fig. 23, p. 58). Tomes describes a tumor of 
this kind which weighed ten ounces. Sutton refers to one which 
weighed seventy ounces. 

5. Compound Follicular Odontomes. — "If the thickened capsule 
ossifies sporadically instead of cu masse, a curious condition is broughl 
about, for the tumor will then contain a number of small teeth or denticles 
consisting of cementum or of dentine, or ever 
ill-shaped teeth composed of three dental ele- 
ments, cementum, dentine, and enamel " (Sutton) 
As many as three hundred to four hundrec 
denticles have been found in a single tumor 
Tumors of this character have been seen in the 
human subject. Tellander met with a case ir 
fig. 313.— Denticles from the a woman aged twenty-seven ; from this tumoi 

compound follicular odontome re- ^ removed the denticles shown in Figure 3 I 3 
moved by lellander (after Sutton). & *J J 

6. Radicular Odontomes. — "This term i; 
applied to odontomes which arise after the crown or the root has beer 
completed and while the roots are in the process of formation " (Sut- 
ton). In the specimen represented in Figure 314 the outer layer of 
the tumor is composed of cementum ; within this is a layer of dentine 
deficient in the lower part of the tumor ; and inside this dentine is 1 
nucleus of calcified pulp. A number of radicular odontomes have 
been observed in the human subject. Suppuration is a common com 
plication of these tumors. 

7. Composite Odontomes. — These are hard tooth-tumors whicl 
bear little or no resemblance in shape to teeth, but which occur in the 




ODONTOMA. 



441 



jaws. The tumors, which consist of a disordered conglomeration of 
enamel, dentine, and cementum, arise from an abnormal growth of all 




Fig. 



314. — Radicular odontome from human subject (after Salter) : a represents the natural size of the 

specimen. 



the elements of a tooth-germ (Fig. 315). In the majority of cases the 
tumors are composed of two or more tooth-germs indiscriminately 
fused (Sutton). It is supposed that odon- 
tomes are more frequent in the lower than 
in the upper jaw, but there is good ground 
for the belief that many such tumors have 
been described as exostoses of the antrum. 
The diagnosis of dental tumors is very 
obscure, and in consequence of faulty 
diagnosis uselessly severe operations have 
often been performed for the removal of 
tumors of this kind. It is important to 
examine solid and cystic tumors of the 
jaws, especially if they occupy the site of tooth-germs, with special 
reference to their possible dental origin. A diagnosis once made, a 
successful operation can be performed with little mutilation. The bone 
surrounding the tumor is removed by subperiosteal resection, when the 
tumor can be enucleated or removed with gouge and mallet. The 
cavity is tamponed for a few days with iodoform gauze. 




Fig. 315. — Composite odontome from 
a young lady aged eighteen ; natural size 
(after Heath). 



XXIII. ANGIOMA. 

Definition. — An angioma is a tumor composed of blood-vessels pro 
duced from a matrix of angioblasts. Angiomata were formerlj 
described as "teleangiectasia," " angiotelectasia," "angioma pleni 
forme," " erectile tumors," and " nsevi." Virchow included all vascula: 
tumors under the head of angioma. Tumors composed of lymphatic 
vessels are called " lymphangioma," to distinguish them from tumor; 
composed of blood-vessels, and this is what is generally understooc 
by the unqualified term " angioma." The definition excludes frorr 
this class of tumors all swellings caused by dilatation of pre-existing 
blood-vessels, aneurysm, and varicose veins. The angiomatous tumoi 




Fig. 316. —Angioma of tongue, showing newly-formed blood-spaces not yet in connection with pre- 
existing vessels; X 330 (Surgical Clinic, Rush Medical College, Chicago): a, angioblast; i, newly-formec 
spaces filled with delicate fibrous network and amorphous material. 

is composed of new blood-vessels which are in communication with 
the adjacent vessels, interstitial tissue composed of the pre-existing 
tissues in which the tumor develops, and the blood contained in the 
vascular spaces. The size of the tumor is very variable at different 

442 



ANGIOMA. 443 

times and under different circumstances, according to the anatomical 
structure of the vessels and the amount of blood the vessels contain. 

Histogenesis. — Weil in a study of the growth of angioma came 
to the conclusion that the origin of new blood-vessels is as variable as 
is the formation of new embryonal vessels. He found projecting 
from the wall of old and new capillary blood-vessels streaks of proto- 
plasm which showed nucleated projections which in the course of time 
became laminated and were traversed by blood from the pre-existing 
vessels. In other places he found proliferation of the endothelial cells 
which formed buds and projected into the surrounding tissues. These 
masses of endothelial cells form new vessels by the formation of hollow 
spaces which communicate with the vessels from which they originated. 
Rokitansky has seen and described the formation in the connective 
tissue of blood-spaces discontinuous with pre-existing blood-vessels, 
and which only later entered into communication with them (Fig. 316). 
In a case of pulsating cavernous tumor of the spleen Langhans noticed 
an extraordinary proliferation of the endothelium of the venous spaces, 
and to this proliferation he ascribes the growth of the tumor, in oppo- 
sition to the theory advanced by Rindfleisch, and the illustrations 
which accompany his paper appear to justify his conclusions. If the 
matrix of angioblasts forms a part of the vessel-wall, the new blood- 
vessels are formed by budding, and are in communication with the pre- 
existing vessel from the beginning. If the angioblasts have become 
displaced into the connective tissue, the tumor-tissue becomes vascular 
after the new blood-spaces have formed a communication with the pre- 
existing vessels. 

Histology. — Angioma is closely related to endothelioma, as its 
cellular elements possess the shape and arrangements of their mother- 
soil. The angioblasts are a modified form of fibroblasts. Their intrin- 
sic function is to produce new blood-vessels. 

In the growth of normal blood-vessels the angioblasts furnish the 
essential tissue-elements of blood-vessels ; the blood-vessels reach their 
requisite normal size, when the process becomes stationary. The angio- 
blasts from which an angioma develops observe no such limitation of 
function ; their function is a progressive one, and their product of tissue- 
proliferation results in the formation of atypical blood-vessels which are 
not required by the part in which they are produced, and which con- 
stitute the essential tumor-tissue. The vascular spaces, whether capil- 
lary, venous, or arterial, are lined with endothelial cells the product of 
the angioblasts. In a growing angioma new blood-spaces continue to 
form, and again enter into communication with the older vascular spaces 
(Fig. 317). As the blood-spaces are formed by the production of an 



444 PATHOLOGY AND TREATMENT OF TUMORS. 

intima from the angioblasts, active proliferation takes place in the 
remaining tissues of the vessel-wall. Connective tissue and muscle- 




Fig. 317.— Angioma of the back ; X no (Surgical Clinic, Rush Medical College, Chicago) : a, wall of blood 
spaces ; b, newly-formed blood-spaces. 

fibres derived from the pre-existing blood-vessels are produced, form- 
ing the outer and middle coats of the new vessels (Fig. 318). The 





vtfw'-'-;^ •■•■■■ i " ■■-/# 



Fig. 318.— Angioma of rib, showing new vessel-wall; X no (Surgical Clinic, Rush Medical College, Chi 
cago) : «, intima; b, adventitia ; c, proliferating cell-areas in the media. 

limits of the tumor, as in all benign growths, are well defined, as wil 
be seen in Figure 319. 

Angioma as a component part of other tumors gives rise to th< 
different combination tumors in which the angiomatous part so ofter 



ANGIOMA . 



445 



constitutes what imparts to the tumor its most serious clinical aspects, 
as in angio-lipoma, angio-fibroma, angio-adenoma, angio-sarcoma, and 
angio-carcinoma. The communication of all angiomata with blood- 
vessels is very free. Virchow and Maier have shown that an angioma 
of the liver can be injected from the hepatic artery and vein and from 
the portal vein. 

Complications. — According to the number and activity of the 
angioblasts, the tumor may grow rapidly, may remain stationary, or in 
exceptional cases may disappear spontaneously. Inflammation occur- 




Fig. 319. — Cavernous angioma of liver; X 30 (after Karg and Schmorl). The tumor (a), which shows 
a well-defined border at its junction with the liver-tissue (6), exhibits a structure similar to cavernous tissue. 
The tumor consists of irregular spaces lined with endothelial cells and separated by their connective-tissue 
septa. The hollow spaces contain blood ; c, a hepatic vein. 



ring spontaneously or produced by artificial means occasionally results 
in a permanent cure. This complication may, however, become a 
source of danger to life from septic thrombo-phlebitis. In venous 
angioma there sometimes forms a thrombus of a plastic character that 
may result in the formation of a phlebolith or vein-stone. Extensive 
thrombosis is one of the ways in which finally all the blood-vessels 
become obliterated. Transformation of an angioma into the most 
malignant form of sarcoma is by no means rare. Such a transition 
is shown in Figure 320. The tumor from which the section repre- 
sented in Figure 320 was taken was a superficial capillary angioma of 



446 



PATHOLOGY AND TREATMENT OF TUMORS. 



the face that had become stationary during childhood in a mar 
twenty years of age. Without any obvious cause the tumor com 
menced to grow very rapidly, and when removed it showed the typica 
structure of a round-celled sarcoma. The section represented in th< 
illustration was taken from the periphery of the tumor. Calcificatior 
of the stroma of the tumor and of the vessel-walls arrests the furthei 
growth of the tumor. The angiomata are occasionally the seat of s 
striking hyaline or colloid change, a cylindromatous appearance ofter 
being given to the tumor. 




Fig. 320. — Capillary angioma undergoing transformation into a sarcoma; X 55 (Surgical Clinic, Rush 
Medical College, Chicago) : a, connective tissue; b, capillary vessel cut transversely; c, capillary vessel cul 
obliquely ; d, group of sarcoma-cells. 

Anatomical Varieties. — The division of angioma into anatomical 
varieties is based on the kind of vessels the tumor-tissue represents. 
In superficial angioma the color of the tumor indicates its structure and 
the kind of blood it contains. An arterial angioma presents the bright- 
red hue of arterial blood ; the red color of a capillary angioma is of a 
less bright hue ; and the venous or cavernous angioma presents the 
dark-blue appearance of venous blood. 

Capillary Angioma — A capillary angioma, known as simple naevus 
or " mother's mark," is the incipient form of vascular tumor. Its 



ANGIOMA. 



447 



favorite sites are the skin of the face and the orbit. The tumors 
are flattened or slightly pendulous, and they are blue, pink, or purple 
in color. The difference in color, varying from a pink to a livid tint, 
depends, according to Billroth, upon whether the vessels be situated 
superficially or deeply. The most superficial form of capillary angioma 
is known as a " port-wine stain." If the terminal veins are involved, 
the tumor is more prominent and of a darker color. The tumor can 
usually be emptied of its blood by pressure ; sometimes, however, this 
cannot be done. The dilated capillaries and veins are separated by 
a variable quantity of connective tissue. If the connective tissue is 
abundant, the tumor is firm ; if scanty, it offers little resistance to 
pressure. As a rule, the tumor-tissue does not extend beyond the 
subcutaneous cellular tissue. The vessels are arranged in small groups 
from the size of a hemp-seed to that of a pea, consisting of dilated 
capillaries and venulae arranged around the appendages of the skin 
(Fig. 321). 

All capillary angiomata are congenital. They may be so small that 




Fig. 321.— Capillary angioma of the skin (after Perls). In the upper layer of the skin can be seen capil- 
laries dilated into cavernous blood-spaces. In the fatty layer only a few capillaries (a), somewhat dilated and 
with thickened walls, can be seen ; b, a sweat-gland. 

they cannot be detected at the time of birth, but they soon begin to 
increase in size, whereas the cavernous angiomata are not always con- 
genital and may develop at any time after birth. Their growth is best 
studied in the subepithelial fat, where the tumor forms small cellular 
masses of angioblasts and connective-tissue corpuscles. 

Cavernous Angioma. — The cavernous angiomata form tumors of 



44 8 



PATHOLOGY AND TREATMENT OF TUMORS. 



larger size than the capillary variety, and are composed of irregulai 
blood-spaces which communicate freely with one another. The new 
blood-spaces are formed by angioblasts in the cellular connective tissue, 
Cavernous angiomata are found in the deep connective tissue, in the 
bones, the liver, the spleen, and the kidney, and are composed of a 
tissue almost identical with that of the corpus cavernosum penis — that 
is, of irregular blood-spaces communicating freely with one another and 
separated by fibrous septa of variable thickness (Fig. 322). The walls 




Fig. 322. — Cavernous angioma of the liver ; X 350 (after D. J. Hamilton) : a, liver-cells at margin of the 
tumor ; b, blood contained in the cavernous spaces ; c, walls of the cavernous spaces. 

of the blood-spaces are lined by endothelium. The formation of new 
blood-spaces takes place in the fibrous septa and in the periphery of 
the tumor. Cavernous angioma is a much more formidable tumor than 
a superficial nsvus, as its tendency to progressive growth is ■ much 
greater and from its deeper location it involves more important struc- 
tures. A simple nsvus may, however, later in life become convertec 
into a cavernous angioma. 

Plexiform Angioma. — Plexiform angioma, which is a true angioma- 
tous tumor, and not an aneurysm, has been known as " aneurysm b> 
anastomosis " or " cirsoid aneurysm " — terms that should no longer be 
employed to designate an arterial angioma. Plexiform angioma con- 



ANGIOMA. 



449 



sists of a number of tortuous blood-vessels of moderate size arranged 
parallel with one another. These tumors, which are composed of 
arteries alone, of veins, or of arteries and veins in equal proportions, 
are found most frequently about the forehead, the temporal regions, the 
fingers, the anus, and the legs. The largest angioma that came under 
the writer's observation was in the axilla of a boy seventeen years old. 
The tumor had existed for many years and had undergone active 
growth for two years. It had reached the size of a child's head. 




Fig. 323.— Dissection of a plexiform angioma of the forehead (after H. Muller). 

Some of the veins were as large as the thumb, and the arteries, several 
in number, were about the size of an ordinary lead-pencil. Pulsations 
and bruit were well marked and extended along the subclavian vessels. 
Preliminary to excision, on two different occasions two of the largest 
arteries that fed the tumor were ligated. The operation of excision, 
despite the preliminary deligation, was an exceedingly bloody one. At 
least fifty compression-forceps were required, and nearly as many points 
were ligated after the excision of the growth. The boy made a good 
recovery, notwithstanding the excessive loss of blood. 

The tumors are found most frequently in young adults, and they 
almost always, sooner or later, manifest progressive tendencies. Plex- 
iform angioma in many instances develops in pre-existing blood-vessels, 

29 



450 PATHOLOGY AND TREATMENT OF TUMORS. 

being then caused by an excessive quantity of angioblasts in the vessel 
wall. During the growth of the tumor there are produced new blood 
vessels which remain in communication with the lumen of the vesse 
similarly affected. Bruit and pulsation are usually frequent, and the 
size of the tumor is greatly diminished by pressure. In cases of 
epicranial plexiform angioma the bone beneath the tumor undergoes 
pressure-atrophy, so that deep depressions occur, and even perforatior 
of the skull may take place. 

Symptoms and Diagnosis. — The diagnosis of a surface angioma 
can be made from the color of the tumor alone. The color depends 
on the kind of blood the tumor contains, and is also modified, accord- 
ing to Billroth, by the amount of tissue over the tumor. In mosl 
instances the color of the tumor disappears under pressure, and returns 
with the entrance of blood into the tumor-tissue. In plexiform angioma 
pulsation and bruit are frequently present, and the tumor almost dis- 
appears under pressure. Any and all of the causes which increase 
intravascular pressure, as coughing, laughing, straining, and active 
exercise of all kinds, increase the size of plexiform and cavernous 
angiomata. In plexiform angioma, if the tumor is subcutaneous, the 
tortuous vessels can be outlined distinctly. 

The differential diagnosis between intracranial angioma and angioma 
of other internal organs and aneurysm is impossible. A positive dif- 
ferential diagnosis between pulsating inflammatory swellings and 
angioma can be made by resorting to an exploratory puncture. 

Prognosis: — Surface angioma in exceptional cases becomes con- 
verted into a plexiform angioma, and not infrequently it serves as a 
starting-point for sarcoma. With the exception of these possible termi- 
nations it is a benign affection. In some cases a spontaneous cure is 
effected ; in other cases a cure follows inflammation occurring acci- 
dentally or produced intentionally. In cavernous and plexiform 
angiomata the prognosis is more grave. Inflammation of such tumors 
may result in septic thrombo-phlebitis, pyemia, and death. Wounds 
of angiomata may give rise to serious and even fatal hemorrhage. The 
progressive growth of a plexiform angioma may interfere by pressure 
with the function of important adjacent organs. Ulceration may resull 
in serious hemorrhage or may give rise to dangerous inflammatory 
complications. 

Treatment. — The probability of the occurrence of a spontaneous 
cure in angioma is so small that operative treatment should be institutec 
in appropriate cases as soon as the tumor is discovered. In the super- 
ficial variety, the so-called " port-wine mark," operative treatment is 
contraindicated if the tumor is diffuse — that is, if it occupies an ares 



ANGIOMA. 451 

larger than a silver dollar. If the tumor is limited, excellent results 
are obtained by electrolysis. Only a small part of the surface should 
be treated at each sitting, and the operation should be repeated every 
few days. Among the other surgical resources which have been em- 
ployed in the treatment of ordinary naevus may be mentioned ignipunc- 
ture, coagulating injections, ligature, and the application of caustics. 
Ignipuncture with the needle-point of a Pacquelin cautery is an excel- 
lent method of treating superficial angiomata in localities not easily 
accessible to excision, as the soft palate and the mucous membrane of 
the mouth and the pharynx. The method can also be employed in 
the removal of surface angiomata in parts of the body not exposed, as 
the chest, abdomen, arms, and legs. The scarring following ignipunc- 
ture is much greater than after excision. The needle should be heated 
to a dull-red heat, as puncturing with a needle heated to a white heat 
is likely to give rise to hemorrhage. The punctures should be made 
a few lines apart and in a circle corresponding with the periphery of the 
growth. The central portion may be treated in the same manner at 
the same time, or this part of the tumor may be treated later. If the 
tumor is larger than a half-dollar, a number of sittings are necessary 
to complete the treatment. Before puncturing the surface should be 
made aseptic, and after the puncturing it should be protected carefully 
against infection. 

Coagulating injections in the treatment of angiomata are mentioned 
simply for the purpose of condemning them. Their employment has 
produced instant death from embolism, and has frequently been fol- 
lowed by suppuration and ulceration. 

The ligature causes pain and sloughing, and the resulting scar is 
more unsightly than that following excision. The ligature is now 
seldom used in the treatment of angioma. The same may be said of 
percutaneous threads saturated with coagulating solutions. Nitric acid 
has been recommended strongly by Billroth and others in the treat- 
ment of circumscribed superficial angiomata. All caustics are inferior 
to the use of the knife. 

The fear of hemorrhage attending the excision of angiomata is 
unfounded, provided the incisions are not made through, but outside 
of, the tumor-tissue, or, as Sutton so happily says, " if the naevus 
is cut out, not cut into." The writer never encountered trouble- 
some hemorrhage when this advice was followed in the excision of 
angiomata. 

The ideal treatment of angioma is excision. The incision should be 
made a fcio lines atcav from the visible boundary of the tumor, on the 
sides as ivcll as at its base. The bleeding vessels can be caught at once 



452 PATHOLOGY AND TREATMENT OF TUMORS. 

with hemostatic forceps, the surgeon being enabled to remove tht 
growth quickly before the bleeding points are tied. Circular pressun 
some distance from the periphery of the tumor is a material aid ir 
diminishing the amount of bleeding. If the wound cannot be closec 
by suturing, the surface should be covered at once by a Wolfe graf 
or by Thiersch grafts. 

The surgical treatment of plexiform angioma has so far not yieldec 
very encouraging results. Ligature of the principal artery of the pari 
occupied by the tumor has not proved satisfactory. Ligature of the 
arteries supplying the tumor has not yielded much better results. Ir 
tumors of moderate size and readily accessible on all sides, excisior 
offers the best prospects. If the tumor is large, as in the case men- 
tioned on page 449, it is well to tie several of the larger vessels prioi 
to the excision. If it is important to make the incision some distance 
away from the growth in the excision of an ordinary nasvus, this advice 
applies with still greater force to the excision of a plexiform angioma, 
The principal vessels which nourish the tumor should be exposed and 
be secured with hemostatic forceps before they are cut. Pressure is 
an important factor in removing provisional hemostasis in the excision 
of a plexiform angioma. In such cases the skin over the tumor should 
be reflected and preserved if it is intact. If the angioma involves the 
skin, this must be excised with the tumor, and the resulting wound- 
surface is paved at once with Thiersch grafts. 

Topography. 
Skin and Mucous Membranes. — The skin and the mucous mem- 
branes are the seats of capillary angioma. The face and the mouth are 
the favorite localities. The most superficial form, the " port-wine mark," 
frequently is very extensive, occupying the larger part of one side of 
the face, and in some instances even one half of the body. This 
variety of tumor is occasionally converted into a cavernous or a plex- 
iform angioma. Breschet relates the case of a girl who was born with 
a port-wine mark on the external ear. The tumor remained stationary 
for several years, when it became the seat of pulsation, ulcerated, and 
bled freely from time to time. In her eighteenth year all the arteries 
in the temporal region were consistently enlarged, as was also the 
occipital, which, together with the tumor, made a pulsating swelling of 
considerable size. At the necropsy it was ascertained that the arteries 
had such thin walls that they could hardly be distinguished from the 
accompanying veins. Breschet believed that the arteries communicated 
directly with the veins. In another case observed by Breschet an 
insignificant angioma behind the ear was followed by dilatation of the 



ANGIOMA. 453 

carotid artery on the same side to three times its natural size ; the aorta 
and the common iliac artery showed similar changes, while the arteries 
of the extremities were normal in size and in structure. The disease 
in this case was progressive, extending from the congenital angioma to 
the vessels mentioned by an uninterrupted process. 

The most typical structure of angioma of the skin is seen in the 
growing tumors in young children. The appendages of the skin in 
the part affected undergo hypertrophy. In port-wine mark the skin is 
but little thicker than normal ; the epidermis is thinner than normal, 
the papillae are flattened, and the epithelial depressions between them 
are more shallow. The arteries and veins can be distinguished with- 
out difficulty, and the dilated capillaries can be identified readily. A 
closer study of the process under the microscope reveals the places 
where the new vessels permeate the fatty tissue. Klebs has seen the 
angioblasts form solid cylinders of cells which project into and displace 
the adipose tissue and which mark the beginning of a new blood- 
vessel. These cell-masses are in immediate connection with open 
vessels, and within the mass can be seen red corpuscles which push 
before them the cellular wall. The new vessel is at first composed 
simply of a tube of endothelial cells. Weil has seen how the angio- 
blasts in pre-existing vessels proliferate and form cell-masses outside 
the vessel-wall ; these masses become hollow cylinders and form new 
vessels. The same process is observed in arteries which supply the 
fat-tissue. According to Ziegler, this process is characterized by active 
karyokinetic changes. The new endothelial cells perforate the muscu- 
lar coat, and outside form cell-masses which are transformed into new 
blood-vessels. Klebs is inclined to believe that other angioblasts find 
their way through the muscular coat by ameboid movements. Most 
of the new vessels are formed from the capillaries in the form of solid 
buds of new endothelial cells. The process is accomplished exclusively 
by the angioblasts. 

All the superficial angiomata are congenital. Port-wine marks 
seldom increase much in size after birth. The deeper variety often 
appears as small red dots not larger than a pin-head at the time of 
birth, but later they increase in size. These small tumors should be 
destroyed by ignipuncture as soon as they are discovered. If the 
tumors are larger than a split pea and occupy exposed parts of the 
body, they should be excised. If the wound is too large to be closed 
by suturing, it should be covered at once by skin-grafts. 

Deep Connective Tissue. — The deep connective tissue is the seat 
of cavernous or plexiform angiomata. The tumors may have their 
primaiy origin in the skin, and reach the deep connective tissue by 



454 PATHOLOGY AND TREATMENT OF TUMORS. 

extension, or may originate primarily in the connective tissue. The 
formation of blood-spaces is not always the result of dilatation b> 
growth of the vessel-wall, but is also produced by confluence. The 
vessel-walls, at points where they come in contact, undergo absorptior 
by pressure-atrophy and impaired nutrition. In cavernous and plex- 
iform angioma the skin overlying the tumor is usually intact if the 
tumor originated primarily in the deep connective tissue. In large 
pulsating tumors the skin is subjected to pressure, becomes atrophic 
and, in consequence of impaired nutrition or of injury, ulceration ma)/ 
ensue, giving rise to recurrent hemorrhages and to infection. Venous 
cysts, which often result from passive dilatation of veins, are a form of 
deep varices, and do not belong to tumors. In other cases such cysts 
occur as a congenital affection, and are discontinuous from pre-existing 
vessels. These cysts are produced by a displaced matrix of angioblasts. 

The frontal and parietal regions are favorite localities for deep angio- 
mata. The tumors are usually congenital, but from their deep location 
they are not discovered until they become larger. W. Koch reports a 
case where, immediately after birth, an angioma the size of a walnut was 
discovered above the right clavicle ; the tumor could be seen through 
the normal intact skin. Uninterrupted slow growth took place until 
the child was eighteen months old, when it died. The tumor then 
measured fifteen inches in a horizontal and seven inches in a vertical 
direction. After the fourth month pressure had no effect in diminish- 
ing the size of the tumor, but brought on asphyctic symptoms. Post- 
mortem examination showed that the tumor was made up of three 
compartments which communicated with one another, of which only 
one compartment answered to the external swelling. Of the othei 
compartments, one occupied the deep region of the neck, and the thirc 
occupied the anterior mediastinum and the right pleural cavity, where 
it had displaced the lung. The chambers contained spaces variable ir 
size occupied by fluid and coagulated blood. The right subclavian veir 
was absent, and the tumor was undoubtedly composed of the tissue: 
which were intended for its structure. 

In a case of cavernous angioma of the arm Esmarch removed ir 
a man twenty-eight years old fifty-four tumors, each of which com 
municated with veins. The first tumor appeared about the region of 
the wrist when the patient was six years old. Esmarch believed tha 
the tumors developed from pre-existing veins. 

The legs and arms, and more especially the fingers, are sometime: 
the seat of plexiform angioma. Vascular tumors of the fingers shoulc 
be excised ; if their size renders this procedure impracticable, multiplt 
ligation should be tried before resorting to amputation. Deep plexi 



ANGIOMA. 455 

form angiomata of the leg and the arm are always grave affections. 
If the extent of the tumor contraindicates excision, multiple lio-ation 
should be tried; in some cases this procedure may be followed by 
excision. In the gravest cases amputation may become necessary. 
Plexiform angioma of the frontal, temporal, and occipital regions should 
be treated by excision with or without preliminary ligation of the prin- 
cipal vessels supplying the tumor, according to the size of the tumor 
and the accessibility of the vessels which feed it. 

Bones. — Most difficult to explain is the origin of vascular tumors 
of bone, called by Virchow myelogenous angiomata. There is good 
reason to believe that pulsating sarcoma of bone has often been mis- 
taken for so-called "aneurysm of bone." Only a very few well-authen- 
ticated cases of myelogenous angioma of bone have been recorded. 
Dupuytren ligated the femoral artery in a case of pulsating tumor of the 
tibia, and the tumor disappeared, but returned (sarcoma) after seven 
years. Virchow in a case of cavernous angioma of the liver found 
also two similar growths in two separate vertebrae. Klebs saw a case 
of genuine bone-aneurysm and cavernous angioma in the same patient. 
The case occurred in Kronlein's practice. The patient was a woman 
twenty-four years old. The tumor was of one year's standing, and 
occupied the upper portion of the vertebral column and the lateral 
aspect of the neck. The tumor was covered by a thin shell of bone, 
and presented neither bruit nor pulsation. On incising the tumor there 
was found a blood-cyst from which at one point there was free hemor- 
rhage. It was ascertained that the hemorrhage was from the vertebral 
artery. As the vessel could not be ligated, hemorrhage was arrested 
by grasping the bleeding point with a hemostatic forceps which was 
incorporated in the dressing. Death occurred from sinus-thrombosis. 
The necropsy showed that the vertebral artery was bent at an acute 
angle and terminated in a network of vascular spaces, and that through 
a small opening these spaces communicated with a large blood-cyst. 
The third and fourth cervical vertebrae were involved by the tumor. 
Microscopical examination of sections of the tumor showed giant-celled 
sarcoma. 

Angioma of bone, as angioma in other localities, is always produced 
by the formation of new blood-vessels from a matrix of angioblasts. 
The differential diagnosis between angioma of bone and myeloid sar- 
coma is impossible. In doubtful cases, in view of the fact that the 
more benign forms of sarcoma have been treated successfully by a local 
operation, it is advisable to resort to removal of the diseased tissue with 
a sharp spoon. Should the subsequent clinical course and microscopical 
examination of the tissue removed reveal the sarcomatous nature of the 



456 PATHOLOGY AND TREATMENT OF TUMORS. 

tumor, amputation should be performed as soon as evidences of ; 
recurrence show themselves. Angioma of bone is an exceedingly rar> 
affection, whereas myeloid sarcoma is common — facts which should no 
be forgotten in the differential diagnosis between these two affection; 
of bone. 

Intracranial Angiomata. — Demme has described blood-cysts of the 
superior longitudinal sinus that perforate the skull and appear exter- 
nally as pulsating vascular tumors. A positive diagnosis between sucr 
cysts and an extracranial plexiform angioma must be made before an 
operation is decided upon. Akidopeirasty with a fine needle will show 
whether or not the skull has been perforated. Intracranial angiomata 
may belong to blood-cysts of bone developed from the vasa nutritia of 
the parietal bone. As the walls of such cysts are lined by endothelial 
cells, the cysts are undoubtedly produced by angioblasts, possibly 
aided by mechanical causes. Other cysts communicating with the 
longitudinal sinus are multilocular. Bruns cites such a case. The 
cyst, which was discovered when the patient was fourteen years old, 
was situated in the parietal region and was composed of veins covered 
by normal skin. The cystic spaces communicated freely with one 
another. In a case of large plexiform angioma of the frontal region, the 
writer, in excising the tumor, found at its base large veins which com- 
municated with the longitudinal sinus. The hemorrhage from this 
source could be controlled only by compression. Death resulted from 
suppurative sinus-phlebitis. 

Angioma in the central nervous system occurs where the vessels 
are all new, all of them starting from the pia. Brunetti found such a 
tumor the size of a pea in the fourth ventricle. Klebs found a similar 
growth upon the surface of the middle lobe. 

Liver. — Cavernous angioma of the liver is of common occurrence. 
It appears in the form of round or wedge-shaped spaces filled with 
blood in parts of the organ not occupied by parenchyma. The spaces 
are nearly uniform in size. New spaces form in the fibrous septa 
and in the periphery of the tumor. It has been asserted that the 
cavernous spaces are formed by dilatation of pre-existing vessels accom- 
panied by pressure-atrophy — an opinion which receives the sanction 
of Ziegler. Such a view is untenable, as the structure of the tumor 
does not represent the conditions produced by vascular obstruction. 
The endothelial cells which line the spaces are attached to and sup- 
ported by a strong scaffolding of connective tissue. In the neighbor- 
hood of such angiomata no evidences of inflammation can be found. 
Johannes Muller found in the lining of such spaces large spindle-shaped 
cells which are the endothelial cells. The number of these cells is not 



ANGIOMA. 457 

the same in all parts of the wall : they are most numerous where the 
process of cell-proliferation is most active, and less numerous where 
the growth of the tumor has become stationary. Similar tumors are 
found less frequently in the spleen and the kidney. 

Mammary Gland. — In rare instances the mammary gland is the 
seat of an angioma. Sutton relates the case of a boy, seventeen years 
of age, who as a child had an ordinary nevus of small size in the skin 
above the left nipple. For many years this nevus gave no trouble ; 
it then gradually increased in size until the whole breast was converted 
into a cavernous angioma three inches in diameter. At intervals the 
surface ulcerated, and profuse hemorrhages were the consequence. 
Another and larger angiomatous tumor of the breast came under the 
observation of Smage. 

Tongue. — The tongue is not infrequently the seat of simple and 
cavernous angioma. In a lad fifteen years old the writer successfully 
removed a tumor the size of a pullet's egg. The excision was greatly 
facilitated by elastic constriction of the affected side of the tongue. 

Muscles. — Cavernous angiomata of the voluntary muscles have been 
observed by a number of surgeons. In the clinic of Rush Medical 
College, Chicago, such a case came under the care of the writer during 
the session of 1894. The patient was a boy sixteen years of age. 
The tumor, which was first discovered five years previously, extended 
from a point three inches above the patella, over the outer aspect of the 
thigh, ten inches in an upward direction. The swelling was oblong, 
very prominent and firm when the patient was standing, but disap- 
peared almost wholly when he was placed in the recumbent position 
with elevation of the affected limb. The tumor, which was removed 
by excision, involved the outer part of the extensor quadratus femoris 
muscle, and extended on the outer side as far as the intermuscular 
septum. A strip of the muscle three inches wide and eight inches 
in length was removed, and on examination it was found to contain 
numerous vessels the size of a crow's quill. The hemorrhage upon 
the removal of the elastic constrictor was very profuse, and about fifty 
vessels had to be ligated before it was controlled. The boy made a 
good recovery and regained perfect use of the limb. The formation 
of a muscle-hernia was prevented by careful suturing of the fascia lata 
with a separate row of buried catgut sutures and rest in bed for six 
weeks. 

Liston removed a cavernous angioma from the popliteal space 
in connection with the semimembranosus muscle. Holmes Coote 
removed a similar tumor from the deltoid, and Campbell de Morgan 
removed one from the semimembranosus in a girl ten years old. 



458 PATHOLOGY AND TREATMENT OF TUMORS. 

In the diagnosis of muscular angiomata the variable size of the 
tumor in different positions of the body is an important element. 

Larynx. — Except in the tongue and the rectum, angioma of the 
mucous membranes is very rare. It has been observed in the laryns 
in a few instances, springing from the vocal cords, the ventriculai 
bands, from the ventricle, and from the sinus pyriformis. Angiomata 
of the larynx are either sessile or pedunculated. They are rarely 
larger than a haricot bean, and are red or purple in color. They should 
be removed with the snare, with the aid of the laryngoscope. 



XXIV. LYMPHANGIOMA. 

Definition. — A lymphangioma is a tumor composed of lymphatic 
vessels produced from a matrix of angioblasts. The lymphatic vessels 
of the tumor are new structures containing lymph, and they constitute 
the essential part of the tumor. Their walls are more delicate than 
those of angioma, but they are composed of the same histological 
elements. A lymphangioma is a firmer tumor than an angioma, as 
the connective tissue between the vessels is more abundant. 

Anatomical Varieties. — Wagner divides lymphangioma into — i. 
Capillary ; 2. Cavernous ; and 3. Cystic. In the capillary variety the 
tumor is composed of lymph-spaces and lymphatic vessels which con- 
stitute an anastomosing network. The cavernous variety is composed 
of a framework of connective tissue with communicating spaces which 
contain lymph. The cystic form presents to the naked eye an appear- 
ance of a convolution of large and small vesicles with translucent walls 
containing lymph. These vesicles are dilated new lymphatic vessels 
which have lost in part or completely their connection with the 
lymphatic system. Such cysts can be produced experimentally in 
rabbits by forcing atmospheric air under considerable pressure into the 
abdominal cavity. Under such conditions the air is forced into the 
lymph-spaces, especially those of the pelvis, producing rapid dilatation. 

Histology and Histogenesis. — In capillary lymphangioma the new 
vessels are formed by angioblasts in the wall of pre-existing lymph- 
spaces by a process of budding, in the same manner as in capillary 
angioma. As the vessels are composed of exceedingly delicate walls 
lined with endothelial cells, they dilate earlier and under less pressure 
than in angioma, consequently cystic dilatation takes place at an earlier 
period and to a greater extent. Capillary lymphangioma is always 
congenital, whereas the cavernous and cystic varieties may develop 
at any time after birth. The beginning of a capillary lymphangioma 
manifests more or less swelling before its lymphangiectatic character 
can be discerned. Microscopically, lymphangioma of the tongue, 
a comparatively frequent affection, appears in the form of a sym- 
metrical swelling of the tongue, while the same affection of the skin 
begins in the subcutaneous connective tissue as a softer swelling with 
ill-defined borders. The loose connective tissue is cedematous, and 

459 



460 PATHOLOGY AND TREATMENT OF TUMORS. 

only in cases where large quantities of clear lymphatic fluid escapes 
can we suspect the existence of dilated vessels. In specimens that an 
somewhat finer, spaces can be seen traversing the tumor, while the 
delicate walls of the ectatic lymphatic vessels and cysts collapse sc 
that the openings in the vessels cannot be seen. Microscopical exam- 
ination, unless carefully conducted, may lead to errors in diagnosis, as 
the specimens often present more the appearance of hyperplasia of the 
tongue than that of dilated lymph-channels. In lymphangioma of the 




Fig. 324 — Lymphangioma of the skin ; X 375 (Surgical Clinic, Rush Medical College, Chicago) : a, connec- 
tive-tissue reticulum ; b, round cells (lymphoid cells) ; c, lymph-space : d, blood-vessels. 

tongue young muscle-fibres are met with, which proves that the mus- 
cular tissue is also increased in quantity. In the subcutaneous tissue 
the growth of lymphangioma is attended by an increase of connective 
tissue (Fig. 324). 

The subcutaneous lymphangioma differs from elephantiasis arabum 
by the tumor being composed of new lymphatic channels instead of 
dilated diseased pre-existing vessels, as is the case in elephantiasis. 
Lymphangioma of the tongue (Fig. 325), or, as it is called, macroglossia, 
is always a congenital tumor. It commences with an enlargement of 
the blood-vessels ; the veins are thin-walled, but a new tissue-product 



L YMPHANGIOMA. 



461 



cannot be recognized so far. On the contrary, the new lymph-spaces 
are dilated and are paved with numerous large nuclei. The dilatation 
of the lymphatic spaces progresses parallel with the new tissue-prolif- 
eration. The muscular bundles are at some points ensheathed by 




Fig. 325. — Lymphangioma of the tongue; X 50 (after I) J. Hamilton); a, lymphadenoid deposits; b, : 
cavernous lymphatic space ; c, muscular fibres of tongue, d, a small artery. 



lymphoid tissue. An increase of endothelial cells is apparent, but 
vessel-dilatation has not as yet occurred. At other points free hyper- 
plastic lymphatic vessels are seen in the connective tissue. In the 
further development of macroglossia, angiomata as well as multilocular 
lymph-cysts appear. If angioma predominates, it is interesting to 
observe that the blood often circulates through the new dilated lymph- 
channels. Liicke observed that on puncturing such cysts, at first 
lymph escaped, and at subsequent repetitions of puncturing blood 
instead of lymph escaped. In such cases the communication between 
blood-vessels and lymphatic vessels is not accidental, but is due to an 
embryonal relationship between the two kinds of vessels. The new 
lymph-spaces contain at first a colorless fluid. Thrombi are also 
found, and their occurrence renders a diagnosis less difficult. Wagner 
found in the lymph ectatic muscular-sheathed hyaline thrombi, and this 
discovery made it easy to give a correct interpretation of their patho- 
logical significance. Lewinski described a case of calcification of 
lymphatic thrombi in a boy twelve years old suffering from lymph- 
angioma of the scrotum. 

Cavernous lymphangioma (Fig. 326) presents upon section a honey- 
combed appearance, the spaces being separated by their septa lined 



462 



PATHOLOGY AND TREATMENT OF TUMORS. 




Fig. 326. — Lymphangioma of the lip; X 55 (after Karg and Schmorl). In the connective tissue under 
the epithelium numerous lymph-spaces of different size, lined by endothelial cells, are seen; these spaces 
contain a few finely granular leucocytes in a mass of lymph (coagulated by hardening). 

with endothelium. The septa are perforated, so that all the spaces com- 
municate with one another. In other cases the interior of the tumor is 




Fig. 327.— Lymphangioma of the orbit ; X 350 (after D. J. Hamilton) : a, stroma of the walls of the cavernous 
spaces ; b, a cavernous lymphatic space ; c, endothelium lining the space. 

occupied by larger spaces, as though coalescence had taken place by 
the breaking down of septa (Fig. 327). The spaces not only undergo 



LYMPHANGIOMA. 463 

cystic dilatation, but are enlarged by coalescence. In some cases hyper- 
plasia of the other tissues also takes place. 

Cystic lymphangioma differs from the cavernous variety only in that 
the individual separate spaces arising from new and dilated lymph- 
channels possess forms which correspond with their origin : they are 
more or less globular in shape, corresponding in this respect with the 
rosary-like appearance of the lymphatic vessels during the early stages 
of the growth of the tumor. Cysts of large size are produced by the 
confluence of numerous smaller spaces. The cystic variety is more 
prone to progressive growth than the cavernous ; in this respect the 
distinction between the two varieties is of importance from a prognostic 
standpoint. This difference in the clinical aspects of these tumors 
applies only to cases where the cysts are multiple, as when only one 
cyst is present its increase in size takes place more on account of reten- 
tion of secretions than by tissue-proliferation. The skin covering the 
tumor is at first intact. As the tumor increases in size it may become 
hyperplasic or it is thinned out by pressure from beneath, constituting 
an important element in the production of ulceration. 

Cystic lymphangioma of the neck has seldom been interpreted 
correctly, and has been described under the vague terms of " cyst 
hygroma," " hydrocele of the neck," " cystic tumor of the neck," "serous 
cyst," etc. Forster first pointed out the correct histogenesis of cystic 
lymphangioma of the neck. He demonstrated the endothelial nature 
of the lining of the cysts by silver-staining. He also showed that these 
cysts communicated with the lymphatic vessels. Luschka asserted 
that the serous cysts of the neck originate from the glainiula carotica 
or from the glomeruli of the artcria intcrcarotica, but in two cases at 
least Arnold was able to show the presence of these organs in a normal 
condition in connection with the cysts. Klebs, who found in a large 
cyst of this kind lymphatic glands in the cyst-wall, believes that the 
glands occasionally take part in the production of the cyst. In none 
of these cases was a connection found between the cavity of the skull 
and the cyst, hence meningocele takes no part in their production ; 
neither was there found any connection between the skull and the cyst, 
hence meningocele can be excluded as a factor in their causation. If 
located in the neck, the cyst may extend in an upward direction as far 
as the cavity of the mouth and downward as far as the mediastinum. 
If very large the cysts become pendulous. Besides the cysts which 
can be seen with the naked eye, endothelial proliferation and the forma- 
tion of new lymphatic vessels can be seen under the microscope in the 
adjacent connective-tissue spaces. In the neck the tumor follows the 
direction of the lymphatics, along the large blood-vessels and the inter- 



464 PATHOLOGY AND TREATMENT OF TUMORS. 

muscular septa. In cases where proliferation is active the blood-vessel; 
are also enlarged, and many of these tumors attain the structure of 1 
mixed tumor — a hazmo-lymphangioma. In such instances the transfor- 
mation of lymph-cysts into blood-cysts, as first described by Liicke 
takes place. 

Multilocular lymphangioma is also found in glandular organs 
Weichselberg reported a case of lymphangioma of the mesentery 
It was a flat tumor, the size of the palm of the hand, between the 
layers of the mesentery at a point corresponding with the upper por- 
tion of the ileum. It contained a fluid which by chemical tests and by 
microscopical examination was shown to be chyle. In the same cate- 
gory belong the congenital cysts of the lung described by Virchow. 
These cysts might be regarded as dilated lymphatics, but the active 
endothelial proliferation which is always found present in the smallest 
lymphatic channels speaks in favor of their being true tumors. 

The kidney is another organ in which multilocular lymphangioma 
is occasionally met with. The histological structure of the cysts in 
this organ is a counterpart of angioma of the liver. The tumor 
is composed of multiple spaces lined by a single layer of endothelial 
cells and communicating freely with one another. The multilocular 
structure of the tumors distinguishes them from retention-cysts of the 
uriniferous tubules. Klebs describes a specimen of multilocular lymph- 
angioma of the kidney. 

Varicose lymphangioma must be distinguished from simple dilata- 
tion of pre-existing lymphatic vessels. It differs from lymphatic vari- 
cosity by the absence of obstruction and by an abnormal increase in 
the amount of lymphatic structures. Dr. Busey, in his monograph on 
Congenital Occlusion and Dilatation of Lymph-channels (1878), describes 
minutely a case that came under his observation. The disease was 
congenital and involved one of the lower extremities, and, as the post- 
mortem showed, extended behind the peritoneum far up into the pelvis, 
The child lived a little more than a year. He collected in addition 
87 cases. In some of them the disease was limited to fingers and toes, 
and resulted in great hypertrophy of all the tissues, including the bones. 
In Busey's case the surface of the limb was covered with translucent 
vesicles which contained a serum-colored fluid. The sweat-glands 
were found enormously hypertrophied. 

A lymphangioma, wherever it occurs, is characterized by the forma- 
tion of new lymphatic structures, the process extending to places in 
which, in normal condition, no lymphatics are found. 

Lymphangioma may occur almost in any part of the body if il 
springs from the perivascular lymph-sheaths. In some cases the pro- 



LYMPHANGIOMA. 465 

liferation is very active and the extension of the disease is progressive. 
The endothelial cells are large, and the connective-tissue reticulum is 
infiltrated with lymph-corpuscles (Fig. 327). Langhans, in a child 
seven years old, saw the disease affect the perivascular lymph-sheaths 
in almost the entire panniculus adiposus, while the large lymphatic 
vessels were free. The inguinal lymphatic glands were permeable to 
injection. Holmes, in a child three years old, saw a case where the 
disease was limited to the right leg. Extension to the external genital 
organs and the lymphatics of the groin and the pelvis took place when 
the child reached its seventh year. A somewhat similar case is the 
one reported by Busey. In this instance the disease extended very 
rapidly, and when the child died the corresponding side of the pelvis 
was found extensively involved. 

Regressive Metamorphoses. — The connective-tissue stroma of 
lymphangioma is subject to nearly all the retrograde tissue-metamor- 
phoses found in other tumors. The most frequent forms of degenera- 
tion met with in such tumors are fatty degeneration and calcification. 
Myxomatous degeneration is liable to occur in large tumors in which 
the connective tissue is abundant. Cystic degeneration by the break- 
ing down of fibrous septa, caused by pressure-atrophy, is of frequent 
occurrence, especially in tumors in which the tissue-proliferation is 
very active and their growth, consequently, rapid. The pathological 
complication that occurs most frequently is thrombosis. Aseptic throm- 
bosis renders the affected part of the tumor harder, and frequently 
results in arrest of growth, as the removal of the thrombi is followed 
by obliteration of the vessels by granulation and cicatrization. The 
enlargement of the tumor caused by this accident under such favorable 
circumstances is followed by progressive shrinkage which attends the 
obliteration of the vessels. Of more serious import is septic tJirombo- 
lymphangitis , which occurs most frequently in connection with ulcera- 
tion of the surface of the tumor. The ingress of pyogenic microbes 
through such an infection-atrium results in suppurative inflammation 
of the walls of the infected lymphatic channels and of the interstitial 
connective tissue. If the suppurative infection is severe, the resulting 
inflammation assumes a phlegmonous character and may successively 
involve the entire tumor, attended by all the risks to life incident to 
septic infection and pyemia. The septic thrombo-lymphangitis is usu- 
ally accompanied by a septic thrombo-phlebitis. In septic thrombo- 
lymphangitis the thrombi are not observed, but they undergo puriform 
softening. 

The transformation of a lymphangioma into a lympho-sarcoma is 
possible, and there is good reason for believing that in cases in which 

30 



466 PATHOLOGY AND TREATMENT OF TUMORS. 

the disease extended over a large territory in a short time, resulting ir 
death, such a transformation had occurred. 

Symptoms and Diagnosis. — Lymphangioma in the majority of 
cases presents itself as a congenital affection with an intrinsic tendenc) 
to increase in size after birth. In some cases the growth is very rapid 
involving different regions successively, and resulting in death by th« 
tumor interfering with important functions. If the tumor is not com- 
plicated by inflammation, it is pale and the overlying skin is intact 
The density of the tumor depends on the amount of connective tissue 
it contains and on the presence or absence of thrombosis. The effect 
of pressure is more marked if the tumor is composed of new blood- 
vessels as well as lymphatic channels — that is, in cases of hemo- 
lymphangioma. If the skin or the mucous membrane is broken anc 
the surface defect communicates with lymphatic spaces, lymph in 
varying quantities escapes. The escape of lymph is the most reliable 
diagnostic clement in the differentiation between a lymphangioma and 
other tumors or inflammatory swellings. The surface of the tumor is 
often undulated from the presence of superficial cysts. Lymphangioma 
of the tongue and the lips can usually be recognized without much 
difficulty. In both instances all the tissues implicated by the tumor 
are in a hypertrophic condition and constitute a part of the swelling. 
Lymphangioma is ordinarily not limited by a well-defined capsule, as the 
connective tissue in the periphery of the tumor is progressively invaded 
by new lymphatic vessels. 

Cystic tumors of the neck, of lymphatic origin, are almost always 
congenital, are thin-walled, and contain a clear serous fluid ; or, if 
hemorrhage into the cyst has taken place, the serum is discolored by 
the admixture of blood. The use of the exploring syringe will fre- 
quently render material aid in the differential diagnosis between cystic 
lymphangioma and other cystic tumors and inflammatory- swell- 
ings. If the exploratory puncture yields first lymph, and later 
lymph and blood or pure blood, the diagnosis of hemo-lymph- 
angioma is established. In the differentiation between a lympho- 
sarcoma and lymphangioma the use of the microscope may be re- 
quired. 

Prognosis. — With few exceptions, lymphangioma is a chronic affec- 
tion and does not tend to destroy life. Great enlargement of the 
tongue in macroglossia may interfere with speech and deglutition. A 
cystic lymphangioma of the neck may become a source of danger by 
interfering with deglutition and respiration. In rapid-growing tumors 
the prognosis should be guarded, more especially if cystic degeneration 
is a permanent feature. The liability to infection, and also to trans- 



L YMPHANGIOMA. 467 

formation into sarcoma, should not be forgotten in the prognosis of 
lymphangioma. 

Treatment. — Complete excision is indicated if the tumor can be 
removed safely. Partial excision is indicated in lymphangioma of the 
lip and the tongue if the tumor interferes with deglutition, speech, or 
respiration, or for cosmetic reasons. In the removal of cystic tumors 
of the neck, of lymphatic origin, it must be remembered that the cyst- 
wall is in close relation with the large vessels, and that parts of the 
tumor often dip deeply into the intermuscular septa. Amputation in 
uncomplicated lymphangioma of the extremities is not a justifiable pro- 
cedure. In cystic tumors of the neck not amenable to enucleation or 
excision a cure may be effected by free excision, cauterization of the 
interior of the cyst with the Pacquelin cautery, and packing of the 
cavity with iodoform gauze. In progressive inoperable cases paren- 
chymatous injection of a 10 per cent, solution of chloride of zinc 
may be tried with a view of arresting further growth by cicatricial 
contraction. 

Topography. 

Tongue. — Lymphangioma of the tongue is known as macroglossia 
(Fig. 328). Clinically, the condition manifests itself as a congenital 
enlargement of the tongue, implicating mainly its anterior two-thirds. 
The growth is progressive, and when the organ becomes too large to 
be accommodated by the cavity of the mouth, its tip protrudes from 
the mouth. The irritation and repeated injuries of the enlarged organ 
by the teeth during mastication, and the exposure of the organ to 
external influences after it protrudes from the mouth, aggravate the 
condition by producing inflammation of the surface of the tongue or 
of the tumor-tissue itself. The disease begins in the submucous con- 
nective tissue, but later implicates the muscular tissue of the tongue. 
Capillary lymphangioma of the tongue is limited to its surface, and 
appears in the form of enlarged papillae. 

The proper treatment consists in partial excision of the tongue if 
the organ has become sufficiently enlarged to interfere with mastication 
and speech. In some cases the lymphangioma is complicated by 
angioma, which calls for special prophylactic precautions to control the 
hemorrhage during the operation. Lymphangiomata of the cavity of 
the mouth have been described by Sachs. 

Lips. — Lymphangioma of the lips is called macrochilia. Billroth 
described a case that came under his own observation. The patient, 
who was fifteen years of age, was born with a diffused tumor of the 
upper lip, which projected considerably beyond the lower lip. The 



468 



PATHOLOGY AND TREATMENT OF TUMORS. 



tumor was painless, firm, pale, and hard, and could not be diminishec 
in size by pressure. It was often the seat of inflammation, and it blec 
readily on being handled or when injured. The tumor was extirpated 
A section through it showed that it was composed of a firm framework 
of connective tissue, the meshes of which were occupied by coagula 




Fig. 328. — Macroglossia in a girl eleven years old (after Humphrey). 



and a serous fluid. The spaces were lined by endothelial cells, and the 
connective tissue contained many elastic fibres. The fluid contained 
lymphoid corpuscles. 

Macrochilia is very rare, and in the cases which have been described 
it was always congenital. As the disease is sure to become complicated 
by repeated attacks of inflammation, it should receive attention during 
infancy or childhood. If the tumor is limited in extent, as in Billroth's 
case, it should be removed by excision. If it is too extensive for 
complete removal, the size of the lip should be reduced to the desired 
extent by wedge-shaped excisions. Under such circumstances Lanne- 
longue's sclerogenic method of treatment deserves a trial. 

Neck. — Many cases of congenital hydrocele or serous cysts of the 
neck are of lymphatic origin. Usually, although not always, they are 



L YMPHANGTOMA. 469 

congenital. The development of the capsule is very imperfect as com- 
pared with true cystomata in the same locality. Arnold divides these 
tumors into superficial and deep. The former are situated between the 
skin and the platysma ; the latter, beneath the platysma, usually along 
the anterior surface of the larger vessels. The deep tumors generally 
reach the greater size. They may surround the whole neck, and may 
extend beneath and below the clavicle, in the direction of the axillary 
space. In an upward direction they may encroach upon the cavity of 
the mouth. Rokitansky and Gurlt believed that these cysts originated 
in the connective-tissue spaces during intra-uterine life. The formation 
of multilocular cysts they explained by assuming that collections of 
serous fluid formed in different parts of the connective tissue at the 
same time. It would be impossible to explain why similar hydropic 
conditions of the connective tissue should not take place in other parts 
of the body if hydrocele of the neck had such an origin. Luschka 
maintained that serous cysts of the neck originated in the ganglion 
caroticum — a theory which does not deserve further consideration, since 
Arnold found this ganglion intact in two cases of hygroma of the neck. 
The existence of an endothelial lining of the cyst in all cases and the 
presence of lymphoid tissue in the cyst-wall leave no doubt that in the 
majority of cases of serous cysts of the neck, of congenital origin, we 
have to deal with cystic lymphangioma. The serum contained in these 
cysts is often stained by the admixture of blood, in which event the cysts 
lose their translucency. If the diagnosis is not clear, an exploratory 
puncture will provide the desired information. The tumor either 
remains stationary after birth or increases very rapidly in size. In the 
former case no treatment is indicated, as a spontaneous cure not infre- 
quently takes place ; if this should not be the case, operative treatment 
is postponed until the child is older. In rapid-growing tumors death 
often results from pressure of the tumor on the trachea, the oesophagus, 
and the large vessels and nerves of the neck. In such cases urgent 
symptoms call for aspiration, which may be repeated as often as the 
pressure-symptoms demand it. In older children strong enough to 
withstand the immediate effects of a radical operation, the tumor should 
be excised, in whole or in part, under strict antiseptic precautions. If 
complete removal is impracticable, the part of the cyst-wall which 
remains should be seared with the actual cautery sufficiently deep to 
destroy its endothelial lining, and the wound should be packed with 
iodoform gauze. Injections of iodine are too uncertain and dangerous. 
Injections of carbolic acid after tapping are less objectionable, and 
should be resorted to if partial or complete excision of the sac is 
contraindicated. 



470 



PATHOLOGY AND TREATMENT OF TUMORS. 



Subcutaneous and Submucous Connective Tissue. — Most of th( 
chronic lymphatic affections of the subcutaneous connective tissue an 
of an infective origin and nature. They are caused by the filaria san 
girinis hominis, and they are prevalent in northern countries, where thi: 
parasite has its habitat. Reference has been made to a case of almos 
general lymphangioma of non-infective origin. True lymphangioma- 
tous tumors of the submucous and subcutaneous connective tissue an 
exceedingly rare (Fig. 329). Steudener described a cavernous lymph- 




Fig. 329. — Busey's case of lymphangioma. 

angioma of the conjunctiva. Biesiadecki found a small lymphangioma 
in the subcutaneous connective tissue. Gjorgewic found a similar tumor, 
the size of a fist, in the subcutaneous tissue of the thigh in a girl nine- 
teen years old. In this case large quantities of lymph escaped through 
two small openings. Reichel described a congenital lymphangioma, 
the size of a pigeon's egg, which he found in the perineum. More 
comprehensive statistics of lymphangioma can be found in the mono- 
graphs on this subject by Busey and Wagner. 

Uterus. — The lymphatic origin of some of the cystic tumors of the 
uterus has been established by Leopold and Fehling. These cysts 
contain a fluid which coagulates on exposure to air, and which is often 
stained by the admixture of blood. The cyst-wall is lined by endo- 
thelial cells. Many of these cysts are multilocular, the septa being 
composed of firm fibrous tissue. The new cysts show in their interior, 
on silver staining, the characteristic reaction of endothelium. In most 
instances these cysts occur in connection with myofibromata. 



XXV. LYMPHOMA. 




Upon histogenetic, histological, and physiological grounds tumors 
of the lymphatic glands should be excluded from tumors of the true 
glandular organs. The lymphatic glands are mesoblastic structures, 
and are not secreting organs. They are hematoplastic organs, physio- 
logically closely allied to the medullary tissue of bone and the spleen. 
They are composed of lymphoid corpuscles and a delicate reticulum 
of connective tissue enclosed in a firmer capsule 
of connective tissue. They contain normally no 
epithelial cells (Fig. 330). The lining of the lymph- 
sinuses and the follicles is composed of numerous 
plate-like connective -tissue cells, in places these 
elements constituting almost an endothelial cover- 
ing. The lymphatic vessels and glands are found 
wherever blood-vessels are present ; besides, lymph- 
spaces are found in the cornea. In the submucous 
tissue lining the different hollow viscera lymphoid 
tissue is found as a diffuse infiltration in the form 

riG. 330. — Elements ofade- 

of follicles (Fig. 33l). noid tiss u e from partially 

a 1 i . • i 1 • ii.i brushed section of lymphatic 

As a lymphatic gland is not a true gland, the glandofa child (after Piersol) . 
tissue composing it is called, from its resemblance <*, fibres of reticulum ; *,iym- 

, , . .... . phoid cells : c, expanded con- 

to glandular tissue, adenoid tissue ; and as it pro- nective-tissue plate, 
duces the lymph, it is also called lymphoid tissue. 

Its essential histological element is the lymphoid cell or lymphoid cor- 
puscle, the product of proliferation of the plate-like connective-tissue cell. 
Definition. — A lymphoma is a benign tumor formed of lymphatic 
tissue produced from a matrix of lymphoblasts. In no department of 
surgical pathology do we meet with more confusion than in the 
differentiation between benign and malignant tumors and infective 
swellings of the lymphatic glands. Virchow includes under the term 
" lymphoma " all tumors and swellings composed of lymphoid tissue. 
Many authors still continue to speak of a " primary carcinoma " of the 
lymphatic glands. Some pathologists entirely ignore the existence of 
non-malignant tumors of the lymphatic glands. This confusion of 
terms and pathological conditions was increased when Billroth intro- 
duced the term " malignant lymphoma." At the present time it is 



472 



PATHOLOGY AND TREATMENT OF TUMORS. 



easier to say what a lymphoma is not than what it is : it constitutes in 
surgical pathology at the present time a veritable lucus a non lucendo. 

Lymphoid tissue is exceedingly susceptible to infection, and i< 
therefore predisposed to acute and chronic inflammation ; it is alsc 
frequently the seat of sarcoma, but lymphoma, in the restricted sense 




Fig. 331. — Diffuse lymphoid tissue occupying 
deeper layers of mucosa of human stomach {after 
Piersol). The lymphoid cells infiltrate the fibrous 
tissue between the glands without being definitely 
limited. 




P 



■mmm 



Fig. 332. — Simple lymph-follicle from the con- 
junctiva of a dog (after Piersol) : a, lymphoid tissue 
limited by the fibrous capsule (3) ; c, surrounding 
connective tissue. 



in which this term will be used here, is exceedingly rare. The resem- 
blance in the structure of tumors and infective swellings of lymphatic 
glands is so close that a reliable differentiation must be based on the 
clinical aspects and the etiology of the different affections of the 
lymphatic glands. Enlargement of the lymphatic glands may be due 
(1) to infection, (2) to sarcoma, (3) to carcinoma, or (4) to lymphoma. 
The acute affections of the lymphatic glands, characterized by rapid 
enlargement, pain, tenderness, and fever, are produced by the entrance 
into the lymphatic system of pyogenic microbes, of the bacillus mal- 
leus, or of pre-formed septic material. If the process is chronic, the 
immediate cause is usually the virus of either syphilis or tuberculosis, 
In leukemia and pseudo-leukemia the infection is diffuse and is unat- 
tended by the usual symptoms which indicate the existence of an acute 
or a subacute inflammation ; the glandular affection either appears 
diffusely from the beginning or becomes diffuse during its course 
These affections point so strongly to the existence of a microbic origin 
that no doubt can be entertained as to their infective origin. Sarcoma 
invades successively the glands of the same chain, and frequently 
terminates fatally by general metastasis. Carcinoma of the lymphatic 
glands is always a secondary affection ; it never occurs as a primary 
disease, as the lymphatic glands do not contain the essential histologica 
elements — epithelial cells. Lymphoma is a tumor of the lymphatic 



L YMPHOMA. 



473 



glands composed of lymphoid tissue ; the growth remains as a local 
affection, and appears clinically as an encapsulated tumor which mani- 
fests no tendency to implicate adjacent glands, and which is never com- 
plicated by affections of other blood-producing organs. The lymphoblasts 
of the matrix of the tumor produce lymph-corpuscles which are not 
transformed into leucocytes, but which remain in the reticulum of the 
tumor as the essential tumor-elements. Lymphoma is a fuuctionless 
tumor, in this respect differing from the hyperplastic, highly active glands 
iu leukemia. 

Histology and Histogenesis. — A lymphoma is not produced from 
pre-existing adenoid tissue, as are the infective swellings. It is the 
product of tissue-proliferation from an embryonal matrix of lympho- 
blasts of congenital or post-natal origin. A lymphoma is a tumor which 
has no more connection with the adjacent lymphatic channels than an 
adenoma has with the surrounding ducts of a gland. The connective- 
tissue plates, modified endothelial cells of the matrix, the lymphoblasts, 
produce the lymph-corpuscles 
which are the essential histo- 
logical elements of the tumor 

(F'g- 333)- 

In its structure a lymphoma 
bears a strong resemblance to 
myeloma (PI. 1 1, Fig. i). The 
lymphoid cells are so numer- 
ous that often they almost 
completely obscure the stroma. 
The capsule of the tumor is 
firm, being composed of con- 
centric layers of fibrous tissue. 
The atypical structure of the tumor is characterized by the absence of 
well-defined lymph-sinuses, while the follicular structure is well pre- 
served. The surface of the tumor is smooth, and lacks completely the 
prolongations into the surrounding connective tissue that are such 
conspicuous features of lymphangioma. The lymphoid corpuscles, 
which are only occasionally present in lymphangioma, form the bulk 
of the tumor in lymphoma. 

Retrograde Metamorphoses. — Permanency of the tumor-tissue as 
compared with the inflammatory products which constitute the infective 
swellings is one of the most important elements in the differentiation 
between a lymphoma and the different forms of inflammatory swellings 
of the lymphatic glands, both acute and chronic. Suppuration can 
occur only if the tumor becomes the seat of infection with pyogenic 




Fig. 333.-